• Feature

    The Competitive Edge of Adaptive Sports

    Participation in sports holds many benefits for individuals with disabilities. PTs, PTAs, and students have important roles to play.

    Feature Adaptive Sports 01

    When Megan Blunk says she spent the year after a devastating 2008 accident "in the dark," the description has a double meaning.

    The Washington state native was 18 and a month out of high school when the driver of a motorcycle on which she was the passenger crashed, resulting in injuries that paralyzed her from the waist down. Blunk had battled depression before the accident. It asserted itself with a vengeance as she envisioned her active life as a multi-sport athlete coming to an end.

    "I had to face everything that I no longer could do. It felt like I was mourning the death of my old life, yet I had to keep on living," she says. "It was incredibly hard. I spent a year in the dark, not knowing if there was anything out there for me."

    Blunk received physical therapist services during that period, but her physical therapists (PTs) were cautious in their treatment and set what struck her as modest goals. She deemed it a "waste of time" and quit. Looking back, Blunk understands and appreciates the need for prudence and safety, but she wishes the PTs had tried harder to push and motivate her.

    Feature Adaptive Sports 02

    Her observations at the time were that "people in wheelchairs always felt sad" and that "nothing seemed exciting about wheelchair sports."

    That all changed one day, when she witnessed a group of wheelchair basketball players moving scrappily around the court on custom chairs and saw that the sport could be "highly competitive" and "badass." Blunt attended a series of wheelchair basketball camps, where her talent was rewarded with a full scholarship to the University of Illinois. She was a member of the United States' gold-medal winning wheelchair basketball team at the 2016 Paralympic Games in Rio de Janeiro. She's now a member of the National Wheelchair Basketball Association's San Diego Wolf Pack, as well as a motivational speaker.

    Blunk is quick to emphasize that she's had "a lot of great experiences" with physical therapy. Still, she regards that first year following her injury—"when I was just blindly trying to have some hope"—with sadness.

    "If any PT I'd encountered then had truly been educated about adaptive sports—like the fact that some colleges offer full-ride scholarships to play them, that there are Paralympics for elite athletes—and, especially," she adds, "if any of my PTs had had personal experience with adaptive sports and felt passionate about it, I'm sure I'd have fed off that excitement and enthusiasm."

    Megan Fisher, PT, DPT, ATC, similarly received what she describes as "pretty conservative" physical therapist services when she returned to the University of Montana after a June 2002 car accident that killed her best friend and required the amputation of her left leg below the knee. "I was 19 years old and was in the clinic with transtibial amputees who were in their 80s and 90s," she says. Like Blunk, Fisher had been a multi-sport athlete who had gained sustenance and identity from those pursuits. The experience in the clinic turned her off. In the process of choosing a career path, she crossed "physical therapist" off the list.

    Instead, Fisher became an athletic trainer. Determined to remain active in sports, she found her way into adaptive cycling. During a 24-hour mountain bike race in 2009, she came to the attention of a member of the US Paracycling Team—which, she says, "led me down that path." Fisher won individual gold and silver medals in paracycling at the 2012 Paralympic Games in London, and individual silver and bronze medals at the 2016 Paralympic Games in Rio.

    As it happened, she was on hiatus from doctor of physical therapy studies at the University of Washington when she competed in London. Satisfying experiences with physical therapy and other factors had convinced her, by that time in her life, to add the letters "PT" to her "ATC."

    Today, Fisher remains a busy athlete when she's not at her day job at Alpine Physical Therapy in Missoula, Montana. She has 4 different legs or blades, depending on the sports activity in which she's engaged. She's happy with where self-motivation has taken her in life.

    Still, she says, "It would've been nice if my PTs had been able to help me get in touch with adaptive sports organizations early on. It might have been a source of support and encouragement, and a way to broaden my perspective and pursuits."

    Dani Burt, PT, DPT, wholeheartedly agrees with Blunk and Fisher about the need for PTs—physical therapist assistants (PTAs), too, she adds—to, at minimum, know enough about adaptive sports to offer resources, such as the names and web addresses of leading organizations, to patients. Burt, however, was in the perfect place to make that connection after a July 2004 motorcycle accident required amputation of her right leg above the knee.

    She rehabbed at Sharp Memorial Hospital in San Diego, which works with the Challenged Athletes Foundation (CAF) and the Amputee Coalition of America to ensure that patients have the information they need on leading an active life and playing sports if they so choose—and the mentoring and other supports they need to get there.

    Finding her way into to adaptive surfing, Burt says, "was a crucial piece in my recovery. I'd always loved the ocean. I just had to figure out a way to get back to it."

    Using funds from a CAF grant, she worked with a prosthetist to fashion a "surf leg," and soon Burt was on her way. By 2016 she'd been crowned the US Adaptive Surfing Champion in the mixed-gender division, and the following year she took the women's division. She also went to school and became a PT—grateful for physical therapy's role in her recovery and wanting to pay that assistance forward to other individuals with physical challenges. She works at Sharp—the same hospital where she recovered from her injuries.

    "In physical terms, surfing has helped me so much," Burt says. "Not only the sport itself but just getting to the ocean. Being able to carry a 9-foot board across soft sand with a prosthetic leg has helped me tremendously in my everyday life. It's contributed to the endurance, strength, and balance I need to tolerate standing for 10 hours while working with patients."

    The message Burt now shares with PTs and PTAs whenever she can is this: "If you can offer patients with amputations and other physical challenges the possibility of engaging in sports, it can completely change their relationship with physical therapy, vastly improve their overall health, and transform their outlook on life."

    Growing Options

    Sports for people with physical disabilities—as opposed to those with developmental or hearing challenges, which have their own histories and signature events (the Special Olympics and Deaflympics)—have come a long way in both tone and growth since 1911, when a "Cripples Olympiad" was held in St Louis.1,2

    Sporting options for physically challenged athletes now run the gamut from, if not A to Z, then at least A to W—starting at archery and running through water skiing and wheelchair basketball, with everything in between, such as boccia ball (adapted bocce), paddling sports, fencing, and scuba diving. Manufacturers make specially designed wheelchairs, water sports equipment, adaptive golf clubs, and other items that facilitate sports participation by individuals with a wide range of physical impairments.

    Competitive opportunities range from recreational local teams and leagues to the Paralympics—a name that, Katie Lucas, PT, DPT, notes, is not short for "paraplegic" but, rather, denotes the event's parallel but equal status, in terms of competition, to the Olympic Games that immediately precede it at the same site.

    But while adaptive sports have grown exponentially in options and participation, too few PTs, says Lucas—echoing the comments of Blunk, Fisher, and Burt—are getting the message and spreading the word.

    "Physical therapy's role in adaptive sports—that of PTs, PTAs, and students—remains in its infancy," Lucas states. She chairs the APTA Academy of Sports Physical Therapy's Adaptive Sports Special Interest Group, or SIG, an entity that aims to speed the maturation process through education—and by connecting PTs, PTAs, and students with clinicians who have adaptive sports experience.

    "The SIG's purpose is to share information and facilitate dialogue, so that people not only know what's out there in terms of options, organizations, and resources, but also so that they feel comfortable getting their patients involved in these sports and getting involved themselves," Lucas says. "There's a lot of room for growth," she adds, "in research, and in terms of identifying and taking advantage of all the ways in which adaptive sports fit into physical therapist practice, enhance wellness, and expand opportunities for patients."

    Existing research leaves no doubt that participation in sports can have profound positive physical and psychosocial effects. A Harris Interactive research study of more than 1,000 adults with disabilities commissioned by Disabled Sports USA and released in February 2009, for example, found that adaptive sports participants tended not only to be more physically active than were their nonparticipating counterparts but also had healthier lifestyles, reported feeling more fulfilled and optimistic, better enjoyed socializing, and were likelier to be employed.3

    A systematic review of studies of the effects of sports engagement by people with amputations that was published in 2011 similarly determined that "participation in sports or physical activity has beneficial influences on the cardiopulmonary system, muscle force, and body mass of individuals with limb amputations"; that "quality of life and self-esteem of individuals with limb amputations were higher than those of people with limb amputations who did not participate in these activities"; and that sports activities helped participants "accept their disabilities and improve their motor skills."4

    "One of the biggest issues facing patients with a disability are the hypokinetic diseases—those caused by lack of activity: obesity, diabetes, hypertension, and heart disease," observes Mark Anderson, PT, ATC, PhD, now retired from the University of Oklahoma, where he shared adaptive sports knowledge and volunteering opportunities with DPT students and those in other health disciplines while working in the school's departments of rehabilitation sciences and family medicine. "Patients who become involved in sports that accommodate their abilities tend to stay physically active longer—with the concurrent benefits of improved fitness, function, wellness, body image and awareness, and socialization." Anderson is a past chair of the Adaptive Sports SIG.

    That all stands to reason, says Jeannette Elliott, PT, DPT, MS, who works in the Division of Disability Resources & Educational Services at the University of Illinois' flagship campus in Urbana-Champagne, and who coauthored, with Maria Thomassie, PT, DPT, an article for APTA's consumer-focused Move Forward PT website titled "Adaptive Sports: Staying Active While Living With a Disability."

    "Participating in adaptive sports offers incredible physical, psychological, and emotional benefits for the body and mind," Elliott says. "It's widely known, and supported by research, that physical activity is great for the body whether or not you have a disability. Sports participation, whether for recreation or competition, can be mentally challenging—requiring problem-solving, motivation, and self-reliance. And accomplishing what you set out to do is emotionally rewarding."

    "Adaptive sports provide participants with a huge mental boost," agrees Thomassie, who did graduate work at Elliott's school. She's now a travel PT and makes it a point to volunteer with adaptive sports teams wherever she's working. "For some of these athletes," she observes, "it's the first time their disability has been normalized."

    A Lack of Awareness

    If there's consensus on the relevance of adaptive sports to the patient-centered goals of PTs and PTAs in general, and in particular to APTA's vision of "Transforming society by optimizing movement to improve the human experience," there's also general agreement on why much of the physical therapy community remains, per Blunk's description, "in the dark."

    Deanne Fay, PT, DPT, PhD, got involved with adaptive sports as a high school student, working with children with developmental disabilities. When she moved to Arizona as "a brand-new PT" in 1990 she looked for opportunities to assist programs serving individuals with any type of disability. By the following spring she was working with adaptive track and field athletes through an organization now known as Arizona Disabled Sports. Fay, who is a professor and curriculum director of the physical therapy department at A.T. Still University's Mesa campus, remains deeply involved in the field, and is a certified international Paralympic classifier in track and field.

    Time and again over the years, Fay has marveled at the therapeutic benefits her pediatric patients have drawn from their athletic pursuits—often, she says, "even greater than things I could accomplish with them in regular therapy." But she's "always shocked," she adds, "by the number of PTs I talk to in my own community who are unaware of the adaptive sports opportunities that are available right here."

    Thomassie sees Fay's shock and amplifies it. She's currently working at a rehab hospital in California, where she recently mentioned adaptive sports in conversation with 2 other travel PTs.

    "Both of them told me, 'I've never seen a wheelchair basketball game. I've never participated in any adaptive sport,'" Thomassie says. "That blows my mind! How can you work in a rehab hospital and never have seen an adaptive sport being played?" Thomassie's current workplace, like many rehab facilities, offers an array of adaptive sports options to patients and community members, she notes.

    "Much of the lack of awareness goes back to PTs' and PTAs' academic preparation," Anderson says. "If you don't have someone on the faculty who has personal experience volunteering in adaptive sports, or if there's otherwise no mention of it in the curriculum, you might never learn about it." Which is more than just a lost opportunity, Anderson believes—it's a "disservice" to patients.

    Lack of familiarity with adaptive sports can "color your entire perception of what's possible for the patient," he says. "You may underestimate some of the capabilities of these individuals. You may think, 'Oh, my gosh, she's got a spinal cord injury' or 'He has cerebral palsy.' Whatever the disability, therapy goals may be significantly underset due to insufficient awareness of what those patients can do."

    Elliott agrees, lamenting a "you are fragile" mindset too often found among those who aren't aware of adaptive sports opportunities—whether they're health care providers or parents. Often, she finds, students with physical challenges arrive at her school—"a campus that's known for its accessibility, accommodations, and adaptive sports options for individuals with disabilities"—underestimating their own abilities. Those students are intrigued by the opportunities they discover to do things in sports that others had long suggested weren't possible.

    The more PTs, PTAs, and students know about specific adaptive sports and the safety features built into their procedures and protocols, Lucas adds, the more motivated they will be to steer interested patients into "fun and challenging athletic activities in which they can succeed."

    Needs and Opportunities

    Anderson has a long history in adaptive sports, having served as medical director of the Oklahoma-based Endeavor Games for 17 years and on the medical staff of the Paralympics. In his posts at the University of Oklahoma, he gave lectures on adaptive sports, brought in adaptive athletes to speak, and provided PT students with many opportunities to see athletes in action and volunteer at adaptive sports events.

    Adaptive Surfer Dani Burt, PT

    "The biggest need with regard to individuals with disabilities is to know what's out there," he says. "Whether you're a student or a PT or PTA, you should be familiar with key organizations and providers of opportunities and resources. I also would encourage schools to offer clinical opportunities that provide students with practical experiences in adaptive sports."

    Fay concurs, saying, "At a very minimum, schools should make certain their graduates are aware of the programs and sports available, so they can seek out local information wherever they end up working. But ideally," she adds, "schools will do more than that. Providing students with opportunities to get personally involved with local adaptive sports programs is the best way for them to see what these activities offer and what these athletes are capable of doing."

    Blunk attests to that.

    "I attended 2 adaptive surf days last summer in Oceanside, California, sponsored by the Stoke for Life Foundation," she notes. "Physical therapy and occupational therapy students from the University of St Augustine for Health Sciences were there to assist the surfers and learn about the sport, and I spoke with them about my experiences as a Paralympian in wheelchair basketball.

    "It was an eye-opening event," Blunk says. "Students told me they gained more insights in that limited period of time than they ever would have imagined."

    "The most effective exposure would be for schools to contact their closest Paralympic sports club," says Thomassie, referring to a nationwide network that provides sports programming to individuals with Paralympic-eligible disabilities. "Students then could go to a competition to observe or volunteer. It's a great way to meet athletes; network with clinicians, other students, and vendors; and collect information and resources that can be of benefit to patients down the road."

    When she arrives in a new city as a travel PT, Thomassie says she starts by clicking on "Find a Club" on the US Paralympics website. "I also research where the rehab hospitals are, because they're typically feeders into local adaptive sports programs." Or, she adds, "I might Google the search term ‘wheelchair basketball'—basketball is my favorite sport—and see if there's a Facebook page for a local team."

    "Unfortunately," she says, "you have to dig deep to get anything close to a comprehensive list of all the different adaptive sports options available in any specific location, because there are so many different sports and groups involved." She, like others interviewed for this article, calls the absence of such a list an unmet need.

    When she does connect with a team, her role may or may not tap her skills as a PT, Thomassie says. "I'll help stretch out the players, serve lunch, keep stats, keep score—whatever they need me to do."

    Burt encourages PTs, PTAs, and students to seek out opportunities to volunteer in adaptive sports, in any capacity.

    "Even if you're just providing a general helping hand, you're gathering information that you can store away and possibly use with patients in the future," she says. "Simply observing how athletes interact with their equipment, or how, in the case of surfing, they get in and out of the water, you're adding to your knowledge base as a PT or PTA."

    "Another area in which we can help is assisting coaches," Fay says. "You might think, ‘I don't know much about that sport,' but that's the coach's job. PTs are movement experts. By applying our biomechanical knowledge, we can help adaptive athletes figure out their strengths and weaknesses and recommend alterations that can improve their performance."

    Shana Harrington, PT, PhD, encourages PTs to seek certification as a para-sport classifier through the International Paralympic Committee. Classifiers assess such factors as types of impairments, severity of disability, and functional limitations in order to group athletes into classes and create a level playing field. Harrington is head of classification in paratriathlon for the International Triathlon Union. She also was Lucas's predecessor in the role of Adaptive Sports SIG chair.

    "PTs are ideal classifiers," says Harrington, a clinical associate professor in the Department of Exercise Science at the University of South Carolina and a board-certified clinical specialist in sports physical therapy. "Range of motion, manual muscle testing, coordination testing—they're all things we do every day in the clinic."

    "Being involved in the adaptive sports world has given me so much awareness about how people with disabilities interact within the community," Thomassie says. "I've learned how far we've come in creating an accessible world, but how much further we have to go. It's increased my empathy and added to my skill set. Adaptive sports awareness and participation is most directly applicable clinically in the rehab, neuro outpatient, and pediatric settings, but there are insights to be gained by PTs and PTAs regardless of practice area."

    Providing a Spark

    Fay recalls one patient in particular who epitomized research on the broad benefits of adaptive sports participation. He was 13 and had hemiplegic cerebral palsy. He had difficulty making social connections in school. He was interested in track, but he lacked the confidence to go all-in because he walked with a limp and doubted he'd ever be able to run.

    "Using my knowledge as a physical therapist of both cerebral palsy and the mechanics of running, I developed activities to help him work on his endurance and speed," Fay says. "We focused on helping him use his involved arm more efficiently during arm swing, increasing the strength of key leg muscles, improving his ability in single-leg stance to improve his landing with each stride, and improving the symmetry of his gait by increasing the step length of his involved side. We were able to change his running gait from what had started as essentially a fast walk and turn it into a true run."

    The teen ended up being able to compete on a local adaptive track team. In fact, his speed was sufficient to allow him to practice the following year with his school's track team for athletes without disabilities, and to compete in exhibition races with that team.

    The experiences did wonders for the teen's self-confidence, Fay reports. "He started introducing himself to people by saying, ‘I'm a track athlete.' He really came out of his shell. It gave him a sense of identity and self-assurance that overflowed to many other areas of his life."

    Witnessing the transformative power of adaptive sports is nothing new for Harrington.

    "Some of my most memorable experiences have been with individuals who sustain devastating injuries and undergo painstaking rehabilitation to get to the point where they see me for classification," she says. "Often they become very emotional because they didn't know they could enjoy anything so much as they do their return to sports and competition. Seeing how much they value that is quite amazing. I'd love more of my peers to experience that."

    From Burt's perspective as an adaptive athlete and a PT, all it might take is 1 glimpse at a previously unimagined future.

    "If you don't know something's possible, you can easily resort to assuming it's not," she observes. "A single photo, video, article, or experience can transcend and transform someone's preconceived notion of what their life can look like."

    Eric Ries is the associate editor of PT in Motion.

    References

    1. Pioneers of Disability Sport. https://www.bristolstreetversa.com/news/pioneers-of-disability-sport/. Accessed March 15, 2019.
    2. De Luigi AJ, ed. Adaptive Sports Medicine: A Clinical Guide. Cham, Switzerland: Springer International Publishing AG; 2018.
    3. Harris Interactive. Sports and Employment Among Americans With Disabilities. https://www.disabledsportsusa.org/wp-content/uploads/2015/11/Sports-and-Employment-Among-People-With-Disabilities-2.pdf. Accessed March 15, 2019.
    4. Bragaru M, Dekker R, Geertzen JHB, et al. Amputees and sports: a systematic review. Sports Med. 2011;41(9):721-740.

    Adaptive Sports, APTA, and VA

    Leif Nelson, PT, DPT, calls a memorandum of agreement (MOA) between APTA and the US Department of Veteran Affairs (VA) that is designed, among other things, to heighten awareness of and participation in adaptive sports by PTs, PTAs, and students a "logical fit" and a "win-win."

    Nelson is director of National Veterans Sports Programs and Special Events at VA.

    Under the MOA, signed by the 2 organizations last December, APTA disseminates information about VA's Adaptive Sports Grant Program, which annually provides up to $15 million to national, regional, and community organizations to increase the availability of adaptive sports activities—from recreational to elite-level—to veterans and service members with disabilities.

    The MOA also enlists APTA in efforts to publicize and encourage the participation of PTs, PTAs, and students in 5 annual VA rehabilitation events for adaptive athletes: the National Veterans Summer Sports Clinic, the National Veterans Golden Age Games, the National Disabled Veterans Winter Sports Clinic, the National Veterans Wheelchair Games, and the National Disabled Veterans TEE Tournament for golfers with disabilities.

    Kara Gainer, JD, APTA's director of regulatory affairs, says information about the grants program and volunteering opportunities is being disseminated through appropriate sections of the association, via newsletters and other means.

    "We are hopeful that, by sharing information with our membership about the VA Adaptive Sports Grant Program and its adaptive sports events, greater numbers of PTs, PTAs, and students will take advantage of opportunities to participate in efforts to help veterans and service members with disabilities maintain a healthy and physically active lifestyle," Gainer says.

    That's Nelson's hope, too. PTs, he says, "have the ideal baseline skillset to elevate the level of care that these athletes receive," yet they are "currently underrepresented" within health teams serving sports-participant veterans and service members with disabilities.

    An array of national, regional, and community organizations receive VA adaptive sports grants to help fund their activities. They ranged in fiscal year 2017 from USA Hockey to the Far West Wheelchair Athletic Association and Row New York.

    "There surely are APTA members who are involved with adaptive sports programs but don't know that this grant money is available," Gainer says. "The physical therapy community can play in important role in seeing to it that local adaptive sports programs get the opportunity to apply for these funds."

    While 3 of the 5 annual VA events for adaptive athletes always are held in the same locations—the National Veterans Summer Sports Clinic in San Diego, the National Disabled Veterans Winter Sports Clinic in Snowmass, Colorado, and the National Disabled Veterans TEE Tournament in Iowa City—the other 2 events travel each year, Nelson notes, which affords geographically desirable opportunities to more prospective volunteers. The National Veterans Golden Age Games for older athletes is being held this month in Anchorage, Alaska, Nelson observes, while this year's National Veterans Wheelchair Games are slated for Louisville, Kentucky, in July.

    "I'm excited about this partnership, from my perspectives as both a PT and a VA official," says Mark Havran, PT, DPT, national lead physical therapist at VA and president of APTA's Federal Physical Therapy Section. "The future is bright for increased participation of our profession in these VA adaptive sports programs."

    Resources

    APTA

    Adaptive Sports USA

    • Registered multi-sport organization of the United States Olympic Committee/US Paralympics dedicated to promoting healthy lifestyles by implementing sports and recreation opportunities for children and adults with a physical disability
      www.adaptivesportsusa.org/

    Adaptive Track & Field USA

    American Academy of Physical Medicine and Rehabilitation

    American Collegiate Society for Adapted Athletics

    Amputee Coalition

    Athletics for All

    • Schools-focused task force of organizations serving students with physical challenges provides tools and guidelines by which coaches, athletic directors, and school administrators can include students with physical challenges in interscholastic sports
      www.athleticsforall.net/

    Challenged Athletes Foundation

    • Provides grant funding for equipment, training, and travel for athletes with physical challenges—of all ages, from beginners to elite level—in 47 different sports
      www.challengedathletes.org

    Disabled Sports USA

    • Offers programs in more than 50 sports for individuals with physical, intellectual, and vision challenges through a nationwide network of more than 120 community-based organizations in more than 40 states
      www.disabledsportsusa.org/

    US Paralympics

    • Division of the United States Olympic Committee responsible for elite sports programming, including sending US Paralympic teams to the summer and winter Paralympic Games; also offers programming to individuals with Paralympic-eligible physical and visual challenges via nationwide network of community-based Paralympic Sport Clubs
      www.teamusa.org/us-paralympics

    Comments

    Thanks for a great article on an important topic. I would like to draw your attention to something one on our students (Jacob Graboski, SPT, Class of 2020) is involved with here in Wisconsin. Might make a nice follow-up to this article. https://www.dairylandgames.org/ http://www.madisonwellnesscollective.org/directory/jacob-graboski Respectfully, Kristi
    Posted by Kristi Hallisy, PT, DSc on 6/5/2019 4:41:20 PM
    I was a co-founder of the Rockies Wheelchair games (pre 1980) while a professor at Colorado State University. I also did adaptive PE for the depart of Exercise science. The games and the training are an absolute for this population.. Craig Rehab's Rec Therapist and we had a ball and the games have gone on.
    Posted by Max Morton on 6/5/2019 6:53:10 PM

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