Lesão e Pessoa com deficiência no Atletismo

. . . Published ahead of Print

Sports Injuries in Paralympic Track and Field Athleteswith Visual Impairment

Marilia Passos Magno e Silva1, Ciro Winckler2, Anselmo Athayde Costa e Silva1,James Bilzon3, and Edison Duarte1

1Department for Adapted Physical Education, University of Campinas, Brazil2Department for Movement Science, Federal University of Sao Paulo, Brazil

3Department for Health, University of Bath, United Kingdom

Accepted for Publication: 19 November 2012

Medicine & Science in Sports & Exercise® Published ahead of Print contains articles in unedited manuscript form that have been peer reviewed and accepted for publication. This manuscript will undergo copyediting, page composition, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered that could affect the content.

Copyright © 2012 American College of Sports Medicine

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Sports Injuries in Paralympic Track and Field Athletes with Visual

Impairment

Marilia Passos Magno e Silva1

Ciro Winckler2

Anselmo Athayde Costa e Silva1

James Bilzon3

Edison Duarte1

1Department for Adapted Physical Education, University of Campinas, Brazil

2Department for Movement Science, Federal University of Sao Paulo, Brazil

3Department for Health, University of Bath, United Kingdom

Corresponding author:

Dr James Bilzon

Address: Department for Health, University of Bath, Bath BA2 7AY UK.

Telephone: +44 (0)1225 383174

Fax number: +44 (0)1225 383833

E-mail: [email protected]

Running title: Injuries in Visually Impaired Athletes

Disclosure of funding: None of the authors have professional relationships with companies

or manufacturers who will benefit from the results of the present study. All authors declare no

conflict of interest.

Medicine & Science in Sports & Exercise, Publish Ahead of PrintDOI: 10.1249/MSS.0b013e31827f06f3

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Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

Abstract

Purpose: The aim of this study was to determine the epidemiology, nature and pattern of

sports injuries in Brazilian Paralympic track and field athletes with visual impairment and

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 T/F12 and 11 were T/F13. A standardised

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, 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%).

Conclusion: 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.

Key words: athletics; disability sport; injury epidemiology; Paralympics

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Introduction

Paragraph Number 1 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 (100m, 200m,

400m, 800m, 1.500m, 5.000m, 10.000m 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 one 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, whilst 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.

Paragraph Number 2 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 5o

in the best eye with the best practical eye correction); B3 are considered to have moderate to

poor vision (from visual acuity above 20/600 to 20/200 or a visual field of less than 20o and

more than 5o in the best eye with the best correction) (22). In track and field athletics, these

classifications are given sport-specific nomenclature, respectively as follows: T/F11, T/F12

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and T/F13. 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).

Paragraph Number 3 The practice of competitive sport predisposes all individuals to sports

injuries, irrespective of disability. It would seem logical to hypothesise that certain

disabilities, such as visual impairment, may predispose athletes to a greater incidence of

sports injuries when compared to able body 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; to direct researchers,

practitioners and administrators to develop preventive strategies and create a safe

environment for participation in training and competition (16).

Paragraph Number 4 Relatively few studies have been conducted into the epidemiology of

sports injuries in athletes with disabilities (7,9,10,11,12,13,19,24,27,28,29,31,33). Most of

these studies have adopted a cross-disability or multi-sport research design creating problems

in interpreting results, since 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

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as an intrinsic risk factor that cannot be modified (24).

Paragraph Number 5 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 (7,10,27). 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 1992, of the 60 multi-disability

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).

Paragraph Number 6 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 aim of

this study was therefore to determine the pattern of sports injuries in visually impaired track

and field athletes from the Brazilian Paralympic team, and assess differences between visual

classes and sexes.

Methods

Paragraph Number 7 This 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.

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Participants

Paragraph Number 8 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 T/F12 and 11 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 standardised 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), Paralympic Games 2008 (China).

Definition of Terms

Paragraph Number 9 A reportable injury was defined as any injury that caused an athlete to

stop, limit or modify participation for one day or more (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, fingers); lower limbs

(pelvis, hip, thigh, knee, lower leg, ankle, feet) and spine (cervical, thoracic, lumbar). The

mechanism of injury was determined as traumatic (resulting from a specific, identifiable

event) or overuse (caused by repeated micro trauma without a single, identifiable event

responsible for the injury) (14).

Paragraph Number 10 Three epidemiological measures (prevalence, clinical incidence, and

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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

Paragraph Number 11 A standardised 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 orthopaedic 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

Paragraph Number 12 Data were collated using Microsoft Excel 2007® and analysed 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

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data distribution. Where the normality of data distribution could be assumed, a one-way

analysis of variance (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.

Results

Paragraph Number 13 Forty 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.

Paragraph Number 14 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.

Paragraph Number 15 With respect to injury mechanisms (Figure 1), overuse injuries were

the most prevalent (82%) and traumatic injuries constituted the remaining smaller proportion

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(p<0.05).

Paragraph Number 16 Figure 2 represents the distribution of sport injuries by body segment,

where the lower limbs appeared to be most affected.

Paragraph Number 17 The frequency of injuries by body region (Figure 3) revealed that the

thighs were most affected.

Paragraph Number 18 The frequency of sport injuries varied by diagnosis (Figure 4), with

the greatest frequencies reported as tendinopathy and spasm.

Discussion

Paragraph Number 19 The 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 (12). In

terms of sports injury prevalence, we demonstrated an overall value of 78%, varying from

82% to 36% across the 5 competitions observed (Table 1). A previous study in track and field

athletes without disability observed an injury prevalence of 42.8% (17).

Paragraph Number 20 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. Whilst these observations were not significantly different, this may be a

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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 sport. In order 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.

Paragraph Number 21 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, that 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.

Paragraph Number 22 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

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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).

Paragraph Number 23 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 (7,9,27). 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).

Paragraph Number 24 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).

Paragraph Number 25 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

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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 (10). According to previous study track and field athletes without

disability sustain injuries mainly in the knee and lower legs (17).

Paragraph Number 26 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).

Paragraph Number 27 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, T/F13) and sex did not reveal any significant statistical differences in clinical

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incidence or Prevalence, but trends suggest they are worthy of further investigation. Further

studies that access the training load, type of event, overall athlete exposure in competition

and training, and relate these data to the sport injury, are important to understand the relation

between the intrinsic and extrinsic factors of sports injuries. This requires a strategic

approach, utilizing electronic sources to optimize the capture and analysis of data.

Acknowledgments

The authors thank all the Brazilian Paralympic Athletes, the Brazilian Confederation Sports

for Blind Athletes (CBDC), the Brazilian Paralympic Committee (CPB) and the Coordination

for the Improvement of Higher Level -or Education- Personnel (Coordenação de

Aperfeiçoamento de Pessoal de Nível Superior-CAPES). The authors do not have any

financial disclosures to report. The present study was unfunded. The results of the present

study do not constitute endorsement by the American College of Sports Medicine.

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Figure Legends

Figure 1 – Mechanism of sport injury in track and field Paralympic competitions

Figure 2 – Distribution of sport injury by body segment in track and field Paralympic

competitions

Figure 3 – Distribution of sport injury by body part in track and field Paralympic

competitions

Figure 4 – Distribution of sport injury by diagnosis in track and field Paralympic

competitions

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Figure 1.

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Figure 2.

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Figure 3.

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Figure 4.

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Table 1: number of participants athletes, injured athletes, sports injuries, prevalence and clinical incidence according visual class, event type and sex.

Visual Class Event type SexTotal

Competitions T/F11 T/F12 T/F13 Track Field Female MaleParticipants

Paralympic Games 2004 4 5 2 11 - 5 6 11IBSA Para Pan-American Games 2005 8 12 8 25 3 7 21 28IBSA World Championship 2007 9 12 7 25 3 8 20 28Para Pan-American Games 2007 7 8 4 19 - 6 13 19Paralympic Games 2008 8 10 4 22 - 8 14 22Total 14 15 11 35 5 12 28 40

Injured athletesParalympic Games 2004 3 5 1 8 - 4 5 9IBSA Para Pan-American Games 2005 3 7 3 12 1 4 9 13IBSA World Championship 2007 6 7 4 14 3 6 11 17Para Pan-American Games 2007 2 4 3 9 - 4 5 9Paralympic Games 2008 2 6 1 8 - 3 5 8Total 12 12 7 27 3 11 20 31

Number of sports injuriesParalympic Games 2004 3 7 1 11 - 5 6 11IBSA Para Pan-American Games 2005 5 8 3 15 1 4 12 16IBSA World Championship 2007 7 14 7 22 6 8 20 28Para Pan-American Games 2007 3 4 4 11 - 6 5 11Paralympic Games 2008 3 6 2 11 - 3 8 11Total 21 39 17 70 7 27 50 77

PrevalenceParalympic Games 2004 75% 100% 50% 73% - 80% 83% 82%IBSA Para Pan-American Games 2005 38% 58% 38% 48% 33% 57% 43% 46%IBSA World Championship 2007 67% 58% 57% 56% 100% 75% 55% 61%Para Pan-American Games 2007 29% 50% 75% 47% - 67% 38% 47%Paralympic Games 2008 25% 60% 25% 36% - 38% 36% 36%Total 86% 80% 64% 77% 60% 92% 71% 78%

Clinical incidenceParalympic Games 2004 0.8 1.4 0.5 1.00 - 1.0 1.0 1.0IBSA Para Pan-American Games 2005 0.6 0.7 0.4 0.60 0.33 0.6 0.6 0.6IBSA World Championship 2007 0.8 1.2 1.0 0.88 2.00 1.0 1.0 1.0Para Pan-American Games 2007 0.4 0.5 1.0 0.58 - 1.0 0.4 0.6Paralympic Games 2008 0.4 0.6 0.5 0.50 - 0.4 0.6 0.5Total 1.5 2.6 1.5 2.00 1.40 2.3 1.8 1.9

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Lesão e Pessoa com deficiência no Atletismo