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00005768-201305000-0001300005768_2013_45_908_magno_paralympic_5miscellaneous-article< 101_0_13_5 >Medicine & Science in Sports & Exercise©2013The American College of Sports MedicineVolume 45(5)May 2013p 908–913Sports Injuries in Paralympic Track and Field Athletes with Visual Impairment[EPIDEMIOLOGY]MAGNO E SILVA, MARILIA PASSOS1; WINCKLER, CIRO2; COSTA E SILVA, ANSELMO ATHAYDE1; BILZON, JAMES3; DUARTE, EDISON11Department for Adapted Physical Education, University of Campinas, BRAZIL; 2Department for Movement Science, Federal University of São Paulo, BRAZIL; and 3Department for Health, University of Bath, UNITED KINGDOMAddress for correspondence: James Bilzon, Ph.D., Department for Health, University of Bath, Bath BA2 7AY, United Kingdom; E-mail: j.bilzon@bath.ac.uk.Submitted for publication June 2012.Accepted for publication November 2012.ABSTRACTPurpose: The aims of this study were to determine the epidemiology, nature, and pattern of sports injuries in Brazilian Paralympic track and field athletes with visual impairment and to assess differences between visual classes and sex.Methods: Forty visually impaired elite Paralympic athletes participated in this study (28 males and 12 females). All athletes competed in International Paralympic competitions between 2004 and 2008. According to the visual classification, 14 athletes were T/F11, 15 were T/F12, and 11 were T/F13. A standardized report form was used to collect injury data during five competitions.Results: Thirty-one athletes reported 77 sports injuries, with a prevalence of 78%, a clinical incidence of 1.93 injuries per athlete, and an incidence rate of 0.39 injuries per athlete per competition. Overuse injuries accounted for 82% and traumatic injuries 18% (P < 0.05). Small variations in the prevalence and clinical incidence of injury between sexes and visual classes were observed, but these were not statistically different (P > 0.05). The highest distribution of injury was in the lower limbs (87%), followed by spine (12%) and upper limbs (1%). The body regions most affected were the thighs (33.8%), lower legs (16.9%), and knees (9.1%). The most frequent diagnoses were spasms (26%), tendinopathies (23.4%), and strains (13%).Conclusions: Elite visually impaired track and field Paralympic athletes present a pattern of overuse injuries predominantly affecting the lower limbs, particularly the thighs, lower legs, and knees. These injuries are associated with tendinopathies, muscle spasms, and strains. There were no apparent differences in injury characteristics between visual classes or sex.Athletics was one of only eight sports included in the first Paralympic Games, held in Rome, in 1960. In this first Paralympiad, only throwing and pentathlon events were performed. In the modern Paralympic Games, track and field athletics is the sport with the largest number of participating athletes, competing in eight track events (100, 200, 400, 800, 1500, 5000, and 10,000 m and marathon), six field events (long jump, high jump, triple jump, javelin, discus, and shot put), and one combined event (pentathlon). They compete in male and female categories and are classified in 1 of the 26 sport classes, according to their disability type and motor function (motor, physical, visual, and intellectual). Athletes who participate in track events use the letter T before the class number to indicate the event type, whereas those participating in field events use the letter F (18). This short introduction serves to highlight the complexity and variety of Paralympic athletic events, which is also reflected in the development and understanding of research in the discipline.To compete, visually impaired athletes must be submitted to a visual classification, where an ophthalmologist evaluates acuity and visual field. Athletes can be categorized in one of three levels: B1 are considered blind athletes (from no light perception in either eye, up to light perception but unable to recognize the shape of a hand at any distance or direction), B2 are considered to have severely impaired vision (from ability to recognize the shape of a hand, up to a visual acuity of 20/600 or a visual field of less than 5° in the best eye with the best practical eye correction), and B3 are considered to have moderate to poor vision (visual acuity above 20/600 to 20/200, or a visual field of less than 20° and more than 5° in the best eye with the best correction) (22). In track and field athletics, these classifications are given sport-specific nomenclature as follows: T/F11, T/F12, and T/F13, respectively. The Track and Field Paralympic Rules determine that acoustic assistance and a guide are permitted for the classes T/F11 and T/F12. Athletes T/F11 should wear opaque glasses to match the capacity of light perception between the competitors. The T/F13 athletes follow the same rules as the regular athletics (18).The practice of competitive sport predisposes all individuals to sports injuries, irrespective of disability. It would seem logical to hypothesize that certain disabilities, such as visual impairment, may predispose athletes to a greater incidence of sports injuries when compared to able-bodied athletes. Epidemiological studies related to sports injuries are therefore important: to allow participants or prospective participants to make informed choices about participating, based on the risk of injury; to provide information for medical and health care professionals to ensure care in disability sport; and to direct researchers, practitioners, and administrators to develop preventive strategies and create a safe environment for participation in training and competition (16).Relatively few studies have been conducted into the epidemiology of sports injuries in athletes with disabilities (7,9–13,19,24,27–29,31,33). Most of these studies have adopted a cross-disability or multisport research design, creating problems in interpreting results because different disabilities may manifest in different injury patterns and frequencies, making it difficult to interpret and apply findings to specific groups, as well as to compare results between studies, with the ultimate aim of reducing injury incidence (13). Sports injuries may also be related to risk factors, which are usually classified as being extrinsic (e.g., sport, rules, climate, surface, equipment) or intrinsic (e.g., body composition, age, sex, flexibility, strength, balance, proprioception), with many intrinsic risk factors considered modifiable (3). With regard to Paralympic sport, the disability must be considered as an intrinsic risk factor that cannot be modified (24).According to previous studies, visually impaired athletes sustain more overuse injuries, in the lower limbs, particularly the knee, leg, ankle, and feet, and the most frequent diagnoses are tendinopathy, strain, and contusion (7,12,27). There are also reports of a relatively high prevalence of injuries to the lumbar and cervicothoracic spine of these athletes (27). During the Paralympic Games in Barcelona in 1992, of the 60 multidisability athletes in the British Paralympic track and field team, 80% were affected by sports injuries (29). Another study, with the Brazilian Paralympic athletics team, revealed that the lower limbs (64.9%) were most affected by injuries, followed by spine (19.3%) and upper limbs (15.8%), and the most frequent diagnoses were tendinitis, strain, and spine pain (33).Unfortunately, to date, there are few published studies that have investigated and reported injuries by sport and disability type, and those do not reveal the true pattern and nature of injuries in elite visually impaired track and field athletes. The aims of this study, therefore, were to determine the pattern of sports injuries in visually impaired track and field athletes from the Brazilian Paralympic team and to assess differences between visual classes and sexes.METHODSThis was a descriptive, observational, analytic epidemiological study regarding sports injuries in visually impaired elite Brazilian track and field athletes from the Paralympic team. Ethical approval was obtained from the University of Campinas Ethical Committee. The Brazilian Paralympic Committee (CPB) and the Brazilian Confederation of Sport for Blind Athletes (CBDC) were in agreement with this study.Participants.Forty elite athletes with visual impairment gave informed consent to participate in this study: 12 were female and 28 were male. With regard to their visual class, 14 athletes were T/F11, 15 were T/F12, and 11 were T/F13. Table 1 presents athletes’ participation by event. All athletes were representing the Brazilian athletic team in international competitions, between the years of 2004 and 2008. Their participation varied depending on squad selection for each event. Sports injury data were collected using a standardized report form, which was used consistently by practitioners during the following competitions: Paralympic Games 2004 (Greece), International Blind Sports Federation Pan-American Games 2005 (Brazil), International Blind Sports Federation World championship 2007 (Brazil), Para Pan-American Games 2007 (Brazil), and Paralympic Games 2008 (China).TABLE 1 Number of participant athletes, injured athletes, sports injuries, prevalence, and clinical incidence according to visual class, event type, and sex.Definition of terms.A reportable injury was defined as any injury that caused an athlete to stop, limit, or modify participation for ≥1 d (9,11). To standardize the location of injury, the body was divided into the following segments and regions: head (head, face), upper limbs (scapular, shoulder, arm, elbow, fore-arm, wrist, hand, and fingers), lower limbs (pelvis, hip, thigh, knee, lower leg, ankle, and feet), and spine (cervical, thoracic, and lumbar). The mechanism of injury was determined as traumatic (resulting from a specific, identifiable event) or overuse (caused by repeated microtrauma without a single, identifiable event responsible for the injury) (14).Three epidemiological measures (prevalence, clinical incidence, and incidence rate) were evaluated in this study. Prevalence is defined as the proportion of athletes who have an existing injury at any given point in time; it is calculated by dividing the number of injured athletes by the number of athletes exposed at the specified time (15,21). Clinical incidence is a hybrid measure of incidence that represents the average number of injuries per athlete; it is accessed dividing the number of injuries by the number of athletes at risk (21). Incidence rate is the number of injuries divided by the total person-time at risk (athlete–exposures) (21). In this study, the athlete exposure was represented by competition and year.Injury report form.A standardized injury report form, used routinely by the CPB and CBDC, required documentation of the following information: athlete name, age, sex, visual classification, sport, event, injured body part, mechanism, and diagnosis of injury. During the competitions, the multidisciplinary Brazilian medical team consisted of doctors, physiotherapists, and nurses. The orthopedic doctors determined the precise diagnosis of each sports-related injury. Sports injuries that occurred outside the period of competition were not recorded. Where athletes suffered a recurrent injury, the injury was counted only once.Statistical analysis.Data were collated using Microsoft Excel 2007® and analyzed using the SPSS 14.0®. Descriptive statistics were calculated and used to determine the total and relative frequency of injuries. The Shapiro–Wilk test was used to determine the normality of data distribution. Where the normality of data distribution could be assumed, a one-way ANOVA test for independent groups was used to assess differences between visual classes and track and field events, and a t-test was used to compare between sexes. Alternatively, the Kruskal–Wallis test was used to assess differences between sexes and visual classes. The acceptance level of significance was set at P < 0.05.RESULTSForty athletes participated in this study and 31 suffered a total of 77 sports injuries (Table 1), which correspond to a prevalence of 78%, a clinical incidence of 1.93 injuries per participating athlete (Table 1), and an average incidence rate of 0.39 injuries per athlete per competition.Female athletes presented a slightly higher prevalence and clinical incidence when compared to male athletes (Table 1), but this was not statistically significant (P > 0.05). With regard to visual class, T/F11 athletes presented a slightly higher prevalence of sports injuries, followed by T/F12 and T/F13 athletes. However, T/F12 athletes showed slightly higher clinical incidence, followed by T/F11 and T/F13 (Table 1). There were no statistically significant differences observed between classifications or groups in these epidemiological data (P > 0.05). When comparing the epidemiological data between event types such as track (sprint, medium, and long distance) and field (throws and jumps), no statistically significant differences were observed.With respect to injury mechanisms (Fig. 1), overuse injuries were the most prevalent (82%), and traumatic injuries constituted the remaining smaller proportion (P < 0.05).FIGURE 1. Mechanism of sport injury in track and field paralympic competitions.Figure 2 represents the distribution of sport injuries by body segment, where the lower limbs appeared to be most affected.FIGURE 2. Distribution of sport injury by body segment in track and field paralympic competitions.The frequency of injuries by body region (Fig. 3) revealed that the thighs were most affected.FIGURE 3. Distribution of sport injury by body part in track and field paralympic competitions.The frequency of sport injuries varied by diagnosis (Fig. 4), with the greatest frequencies reported as tendinopathy and spasm.FIGURE 4. Distribution of sport injury by diagnosis in track and field paralympic competitions.DISCUSSIONThe results of this study demonstrate that the overall clinical incidence was 1.93 injuries per injured Paralympic athlete during the period of observation, indicating that many athletes sustained multiple injuries (21). Paralympic track and field is considered a low risk sport when compared to other Paralympic sports modalities (10). In terms of sports injury prevalence, we demonstrated an overall value of 78%, varying from 82% to 36% across the five competitions observed (Table 1). A previous study in track and field athletes without disability observed an injury prevalence of 42.8% (17).When comparing sports injuries by sex, female athletes presented a slightly higher prevalence (92% vs 71%) and clinical incidence (2.3 vs 1.8 injuries per athlete) of injury (Table 1) compared to males. This trend suggests that a higher proportion of female athletes were injured and those that were sustained more injuries per athlete compared to males. While these observations were not significantly different, this may be a function of the relatively small sample size stemming from a single nation team. There seems to be very little difference in the pattern of injuries between men and women when comparing the same sports among able-bodied athletes (30). A review article suggests that the risk of sports injuries is lower in female than in male athletes without disability (20). Clearly, further studies should be encouraged to evaluate the risk of injury by sex in Paralympic sports. To address this question fully, greater statistical power is required, which may ultimately require the collection and collation of data, using common injury reporting methods across multiple nations.With regard to visual class, T/F11 athletes presented a higher Prevalence of injury, but B2 athletes a higher clinical incidence; this means that a larger percentage of T/F11 athletes was injured, but B2 athletes sustained more injuries, but no statistical significance was revealed. In addition, another study with 131 visually impaired athletes affirms that the prevalence of injury is greatest among athletes with the greatest visual impairment (24). This can be related to the fact that postural stability is affected by vision (2), and proprioception in blind individuals tends to be worse than in those with partial vision resulting in abnormal gait and biomechanics, which can lead to injuries (34). These findings suggest that the implementation of proprioception training, as a preventive measure, may be useful to reduce the prevalence and clinical incidence of sports injuries in athletes with visual impairment.Overuse injuries were most frequently observed in this population. This mechanism of injury is not atypical in sport modalities characterized by repetitive weight-bearing movements, particularly where there is relatively little or no contact between the competitors (5). Able-bodied track and field athletes also have the predominance of overuse injuries (4). During training and competitions in running events for able-bodied athletes, the musculoskeletal system is exposed to long periods of repetitive stress, and it is estimated that the feet strike the floor 1000 to 1500 times per mile (26) with forces two to three times the body mass (32).With respect to the body segments, the lower limbs were most affected by sports injuries. Again, this is possibly because this sport has a large number of events that cause an overload in this body segment. In general, visually impaired athletes sustain more injuries in the lower limbs (7,11,27). Non–visually impaired track and field athletes also present a high frequency of sport injuries in the lower limbs, suggesting that the type and frequency of injuries are related more to the sport than the disability per se (1,35).Athletes with disabilities are often referred with soft tissue injuries (tendons, ligaments, muscle, joint capsule) (13,27,28). The same distribution pattern was found in this study, where tendinopathies, spasms, and strains were the most common injuries. In able-bodied athletes, muscle strains, inflammatory conditions, and joint sprains are also common types of injury (17,35).The thighs were particularly affected by spasms and strains. This body part incorporates biarticular muscles (e.g., hamstring and rectus femoral), which are predisposed to injuries, often during explosive movements such as accelerations out of the starting blocks, or deceleration movements, particularly in sprinters (4,23). Tendinopathies predominantly affected the thighs, knees, and lower legs, probably because these structures appear extremely prone to injuries associated with overload and repetitive movements, as previously discussed. In addition, athletes with visual impairment may expend more energy than other athletes when performing athletic events and are more likely to fatigue quickly (25). This may, in part, predispose these athletes to a higher incidence of overuse injuries in the lower extremity (12). According to a previous study, track and field athletes without disability sustain injuries mainly in the knee and lower legs (17).Injuries to the spine were responsible for 12% of all injuries, particularly in the lumbar spine (9.1%). A previous study has demonstrated a relationship between visual impairment and changes in posture, where visual impairment predisposes individuals to pathologies in the spine, such as scoliosis (8). In addition, running causes a compressive force in the lumbar spine that increases with the velocity and during the impact phase (6). A good physical assessment to identify muscle imbalances related to posture, and the implementation of core stability training can work as a preventive measure to avoid the development of injury in this group. The upper limbs exhibit an injury prevalence of 1.3%, represented by one athlete that competed in throwing events (discus, shot put, and javelin) and sustained a finger injury. In able-bodied athletes, upper limb injuries are also related to throwing events (35).Analyzing the patterns of the mechanism and distribution of sports injuries in this study, and comparing them with previous studies with non–visually impaired athletes, it seems logical to summarize that the prevalence of overuse injuries in the lower limbs is inherently related to the sport, particularly the repetitive movements associated with weight-bearing, rather than the disability itself. This study demonstrated that in visually impaired track and field athletes, the lower limbs were most affected by tendinopathies, spasms, and strains, particularly in the thighs, legs, and knees. Variables such as visual class (T/F11, T/F12, and T/F13) and sex did not reveal any significant statistical differences in clinical incidence or prevalence, but trends suggest they are worthy of further investigation. 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