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"What Do You Mean, A Wheelchair Athlete?"

Webborn, Nick MBBS, FACSM

doi: 10.1249/JSR.0b013e31822d3d90
Invited Commentary

Address for correspondence: Nick Webborn, MBBS, FACSM, Sussex Centre for Sport & Exercise Medicine, Chelsea School, University of Brighton, Eastbourne, United Kingdom (E-mail:

The term "wheelchair athlete" evolved as a term as sports in wheelchairs developed and became more prominent. However, as we look forward to the largest Paralympic Games ever in London in 2012, is this term still valid? With more than 4,000 athletes participating in 20 different sports with a variety of impairment types, it has become evident that, in terms of understanding patterns of injury or illness, this generic term is misleading.

A review of the epidemiology of injuries in sports for people with disabilities shows that this topic has received relatively little research attention (3). Early researchers combined data from different sports and reported the patterns of injury by self-report (1,2). Although these were major efforts in breaking into this unknown world, this approach has limitations. Our understanding of good injury surveillance has made great strides, with one of the foremost conferences in the sports medicine calendar, now hosted by the International Olympic Committee, focusing purely on injury prevention. We need to be more specific in research in Paralympic sports to have a clear understanding of injury etiology to enable effective prevention strategies.

So what does the term "wheelchair athlete" really mean? Sixteen of the 20 Summer Paralympic Sports will involve some athletes who use wheelchairs some of the time, either for their sport or for activities of daily living. Should we use the term "wheelchair athlete" for a swimmer or a power lifter, for example, who uses a wheelchair on a daily basis but not for his or her sport? From an injury perspective, the use of the wheelchair has implications for loading the shoulder that may affect his or her performance in the sport. Equally, injury to the shoulder through sport may affect activities of daily living, such as transfers to and from the wheelchair. Also, there are athletes who participate in sports that use a wheelchair, e.g., basketball or tennis, but are fully ambulant with a prosthesis for a lower limb amputation. Then, consider Boccia, which is a form of boules for people with more severe disabilities, who largely use powered wheelchairs. These athletes do not propel themselves in daily living, and their chairs are stationary while they are undertaking the sport. Within a sport such as sailing, there may be one member of a three-man crew who uses a wheelchair in daily living. An archer with multiple sclerosis perhaps might use a wheelchair for daily ambulation but will sit on a stool to undertake his or her sport. One could continue similarly with examples for more established Paralympic sports like table tennis, equestrian dressage, or shooting, but new sports continue to evolve, such as rowing, introduced in Beijing in 2008 with fixed-seat rowing for wheelchair users. One can see how this all-encompassing term is becoming increasingly misleading.

Sports wheelchairs also have evolved massively during the last 20 years. In the early days of sport for people with disabilities, the athletes would use the same wheelchair provided by the health care provider for daily living and sport. However, the limitations in performance soon frustrated users, and adaptations were made. Early reports of injury may not reflect the current risks given the massive change in the technology of the chair. Wheelchairs became sport-specific in design and started to employ lighter materials such as carbon fiber or titanium, often patterned on cycling technology. Chair designs became specific to the sport, and hence, design factors such as the seating position, camber angle of the wheels, chair length, height, and use of additional rear casters for stability became specific not only to the sport but also to the individual athlete and his or her particular impairment. The biomechanics of pushing in each sport is different, and consequently the tissues put under load vary by sport. If we aggregate data on injury surveillance purely by wheelchair users in sports, we further confuse ourselves in our understanding of injury type and causation. Even within a sport, one will see marked variation in pushing technique. Moreover, in the same event in wheelchair athletics, there will be different classes of athletes competing who will have different abilities to apply propulsion. A low-level paraplegic will have full trunk activity compared with a higher-level paraplegic, who is different, in turn, from a tetraplegic athlete, who has no trunk function and weakness in the upper limbs. Wheelchair rugby is a sport for people with impairment in all four limbs, and predominantly, participants are those with spinal cord injury. The difference in one cervical level of injury leads to a significant alteration in the ability to push and the technique used to do so.

Traditionally, and for convenience, we have lumped together athletes who use a wheelchair in some form or another in a descriptive term, i.e., "wheelchair athletes." However, for effective injury prevention, we have to discard this generic term. Although some researchers have started to study sport- and disability-specific injury patterns occurring during the Winter Paralympic Games and have achieved some success in injury prevention, this remains a snapshot in time of injury occurrence (4). It is necessary for us to accumulate longitudinal data, with detail on exposure to training and competition, and relate those to the specific sport and the specific impairment type and the level of impairment. Longitudinal data are important for understanding not only how injury affects sport participation and performance but also the longer-term consequences of participation in sport. Will athletes in particular sports develop problems that limit their ability to undertake activities of daily living in later life? The health-maintenance consequences of being unable to participate readily in physical activity for health are at least as significant for people with disabilities as for their able-bodied counterparts. We must monitor and assess the effect of sport performance on future ability to undertake activities of daily living and maintain an active lifestyle. Hopefully, future articles reporting injuries in athletes with disabilities will adopt this approach, and we will have a clearer picture of injury risk for athletes of defined impairment types and severities that will allow the development of appropriate prevention strategies and guide future research.

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1. Curtis KA, Dillon DA. Survey of wheelchair athletic injuries: common patterns and prevention. Paraplegia. 1985; 23:170-5.
2. Ferrara MS, Davis RW. Injuries to elite wheelchair athletes. Paraplegia. 1990; 28:335-41.
3. Webborn N. Paralympic sport. In: Caine D, Harmer P, Schiff M, editors. Epidemiology of Injury in Olympic Sports. London (U.K.): Wiley-Blackwell; 2009. p. 475-90.
4. Webborn N, Willick S, Reeser J. Injuries among disabled athletes during the 2002 Winter Paralympic Games. Med. Sci. Sports Exerc. 2006; 38:811-5.
© 2011 American College of Sports Medicine