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Original article
Fit and healthy Paralympians—medical care guidelines for disabled athletes: a study of the injuries and illnesses incurred by the Polish Paralympic team in Beijing 2008 and London 2012
  1. Wojciech Gawroński1,2,
  2. Joanna Sobiecka3,
  3. Jacek Malesza4
  1. 1Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, Kraków, Poland
  2. 2Head of Medical Mission Paralympic Games 2008 and 2012, Polish Paralympic Committee, Warsaw, Poland
  3. 3Faculty of Motor Rehabilitation, Academy of Physical Education, Kraków, Poland
  4. 4Department of Traumatology and Orthopedics, Praski Hospital, Warsaw, Poland
  1. Correspondence to Dr Wojciech Gawroński, Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, ul. Śniadeckich 10, Kraków 31-553, Poland; w.gawronski{at}medicinasportiva.pl

Abstract

Background Successful performance in Paralympic Games (PGs) requires continuous monitoring of the athletes’ health and optimal medical care.

Objective To present the health status and disability category of Polish athletes at the Beijing and London PGs, as well as to compare the injuries and illnesses incurred during both PGs in view of the more stringent healthcare guidelines implemented before London.

Methods The preparticipation examination (PPE) involved general medical/orthopaedic examination, ECG, blood and urine tests. The mandatory periodic health evaluation (PHE) introduced before London comprised general medical/orthopaedic/dental examination, anthropometric measurement, ECG, stress test, laryngological and ophthalmological consultations, and blood and urine tests. The incidence rate (IR) for all injuries/illnesses with 95% CI, incidence proportion and exposure data (athlete-days) were calculated.

Results There were 91 Polish Paralympians in Beijing and 100 in London. Medical consultations decreased from 151 to 74 (injuries: 57 vs 24 and illnesses: 94 vs 50). In both PGs, respiratory tract infections (RTIs) were the most frequent: IR increased from 15.2 in Beijing to 18.1 in London/1000 athlete-days (95% CI 9.7 to 20.7 vs 11.5 to 24.7). In both PGs, most injuries/illnesses concerned Paralympians with spinal cord injuries. The PPE before both PGs confirmed the disability type according to the general medical classification and revealed no health-related contraindications. Only 6.6% of athletes before Beijing but 100% before London had undergone the multispecialist PHE.

Conclusions In both PGs, illnesses were more frequent than injuries. RTIs presented a serious problem. Some groups of disabled athletes are at an increased risk of injury/illness. The more stringent medical care guidelines before London may have caused staggeringly better results.

  • Disabled
  • Sporting Injuries
  • Evaluation
  • Athletics
  • Olympics

https://doi.org/10.1136/bjsports-2013-092298

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    Introduction

    Athletes’ health status has a direct impact on their performance; hence, appropriate medical care has become indispensable for success in competitive sports. An unexpected injury or illness may limit the endurance capacity, or even lead to disqualification, thus cancelling many years of preparation.1 The injuries incurred by able-bodied and disabled athletes are alike, and result from acute injuries or from musculoskeletal overuse.2 ,3 Yet, from the clinical point of view, disabled athletes are at a higher risk of injury/illness due to the impact of their specific disability: for example, the asymmetry of movement, as a result of a missing limb, often leads to backache, while paraplegia or quadriplegia may lead to urinary bladder infections. Hence, the athlete's disability, with the ensuing specific dysfunctions, may predispose to certain disorders, thus making them potentially more frequent in disabled than in able-bodied athletes.4 ,5

    Preventing adverse health events is a challenge for the athletes, their coaches and the national medical team.6 ,7 Various analyses have been conducted of the injuries and illnesses related to the Olympic Games (OGs),1 ,8 ,9 international sports events,10 ,11 particularly football,12 ,13 and national multidiscipline Olympic teams.14 ,15 There are also a number of scientific studies on the injuries and illnesses in disabled athletes and the medical attention they receive.16–20 However, only few focus on a specific national representation.2 ,21–23

    Periodic health evaluation (PHE) and preparticipation examination (PPE) are crucial in the assessment of the athletes’ health status and predisposition to injuries and illnesses.24 ,25 Several authors have described the introduction of PHE before football championships.26–28 Some authors have focused on sudden cardiac death prevention,29–32 confirming its drop as a result of the introduction of 12-lead ECG into PPE.33 ,34 To the best of our knowledge, other than the large-scale prophylaxis programme in the Norwegian team before the Vancouver OGs,1 there are no studies showing the effect of PPE on decreasing the number of injuries and illnesses among athletes.

    The aim of this paper is to present the health status and disability category of Polish athletes before the Paralympic Games (PGs), as well as the injuries and illnesses incurred in Beijing 2008 and London 2012 in view of the more stringent healthcare guidelines introduced before London. As the introduction of prophylactic PPE and PHE in disabled athletes has not as yet been hypothesised in the literature, an additional goal of this paper is to bridge this gap by presenting the medical care guidelines implemented in disabled Polish athletes before the London 2012 PGs.

    Material and methods

    Subjects

    The study analysed the Polish Paralympic team at two consecutive PGs: Beijing 2008 and London 2012. In Beijing, there were 91 physically disabled athletes who competed over a period of 21 days. In London, there were 100 athletes, including the intellectually disabled, who competed for 16 days. In both PGs, the athletes competed in 11 disciplines. The mean age of the respondents in Beijing was 32±11 and 32±10 years in London. Fifty athletes took part in both PGs35 ,36 (table 1).

    View this table:
    Table 1

    Polish Paralympic competitors by sports discipline in Beijing 2008 and London 2012

    Methods

    Before the 2008 Beijing and 2012 London PGs

    Three months before leaving for Beijing, the nominated competitors underwent an ad hoc PPE to assess their general condition and disability category.37 ,38 Additionally, the chief of the medical mission verified compliance with the Sports Minister's ordinance to perform a mandatory PHE.39

    Three months before leaving for London, to ensure the athletes’ health and safety during training and competition, the following minimum requirements were introduced:

    • Multispecialist PHE, as recommended by the Polish Health Minister,40 no later than 6 weeks before leaving for London;

    • PPE for all athletes who qualified for PGs and verification of the multispecialist PHE, no later than 2 weeks before leaving for London;

    • Non-compliance resulted in exclusion from the Paralympic representation.

    The ad hoc PPE consisted of: general medical examination with orthopaedic elements, assessment of disability category, ECG, and blood and urine tests. The PHE consisted of a general medical examination, anthropometric measurement, orthopaedic and dental examination, ECG, stress test, laryngological and ophthalmological consultations and a broad spectrum of blood and urine tests.

    During the 2008 Beijing and 2012 London PGs

    Any instances of illness or injury among the Beijing and London Paralympians were reported by two team physicians responsible for completing purpose-designed paper-based medical forms. Data collection started on arrival in Beijing or London and ended on the last day of the Games.

    The obtained medical data were divided into injuries (acute and chronic) and illnesses. Injury and illness were defined as any symptom that received medical attention. Injury was defined as a newly acquired musculoskeletal symptom8 ,11 or an exacerbation of a pre-existing (chronic) injury that occurred during training and/or competition. The severity of injury was defined in terms of the number of days for which the athletes had to interrupt their normal training programme41 due to the severity of the damage incurred.42 The same applied to the course of illness, defined as any newly-acquired non-injury (or acute exacerbation of a pre-existing or chronic complaint).1 ,9 ,12 ,13

    The incidence rate (IR) for all injuries/illnesses/1000 athlete-days, the incidence proportion (IP): percentage of athletes with injury/illness with 95% CI, and exposure data athlete-days (total days-stay×team size) were calculated according to the consensus statements, previous studies and epidemiological concepts in sports injury/illnesses research.7 ,9 ,10 ,43 The data were processed with Excel and presented in tables.

    Results

    Before the 2008 Beijing and 2012 London PGs

    The PPE carried out 3 months before Beijing revealed no significant health-related contraindications for PGs participation. However, a further verification showed that only six of the nominated Paralympians had undergone the mandatory multispecialist PHE.39

    In contrast, before the London PGs, all the athletes underwent the multispecialist PHE.40 No absolute contraindications to physical training and PGs participation were identified. However, in some cases, the Paralympic nomination was conditional upon undergoing treatment and follow-up examination.

    The PPEs carried out by the Chief of the medical mission in the month prior to the PGs, in Beijing as well as London, confirmed the type of disability: physical, intellectual or visual, and the disability category according to the general medical classification44 (table 2).

    View this table:
    Table 2

    Polish Paralympic competitors by disability category in Beijing 2008 and London 2012

    There were fewer visually impaired Paralympians in London than in Beijing. Intellectually disabled athletes were present only in London. Physical disabilities were predominant in Beijing as well as London, and included four categories: upper/lower limb amputees (27.5% Beijing vs 23% London), athletes with spinal cord injuries resulting from mechanical trauma or spinal cord diseases (24.2% vs 22%), cerebral palsy—athletes with paralysis of extremities or spastic paresis resulting from cerebral trauma or diseases of the central nervous system (18.7% vs 11%) and les autres—athletes with other forms of physical impairment involving different types of paralysis and paresis, deformation, stiffness, contractions or ankylosis/orthodesis, juvenile rheumatoid arthritis with contractions, cyphoscoliosis, arthritis and osteoporosis, muscular dystrophy, haemiplegia, haemiparesis, and congenital defects of multiple sclerosis and comparable diseases (14.3% vs 27%).

    Injuries and illnesses during the 2008 Beijing and 2012 London PGs

    During the 21-day stay (1911 athlete-days) in Beijing, as many as 151 medical consultations took place among the disabled athletes. The number was practically halved during the 16-day stay in London (1600 athlete-days), with only 74 consultations. This concerned injuries as well as illnesses. In Beijing, 57 injuries were reported in 34 athletes, while in London 24 injuries were reported in 16 athletes. With regard to illnesses, 94 instances were reported in 50 athletes in Beijing versus 50 illnesses reported in 31 athletes in London. The IP per 100 athletes for both PGs are shown in table 3.

    View this table:
    Table 3

    Incidence proportion of injury and illness during the Beijing 2008 and London 2012 PGs

    The IR for total injuries was 29.8/1000 athlete-days (95% CI 22.1 to 37.6) in Beijing, and it decreased to 15/1000 athlete-days (95% CI 9.0 to 21.0) in London. In Beijing, the IR for acute injuries, involving muscle contusions or strains (I°), and soft tissue abrasions or bruises was 12.6/1000 athlete-days (95% CI 7.5 to 17.6), and it was lower than the IR for chronic injuries of the musculoskeletal system and overuse (exacerbation of existing complaints), which was 17.3/1000 athlete-days (95% CI 11.4 to 23.2). In London, the IR for acute musculoskeletal system injuries decreased to 8.8/1000 athlete-days (95% CI 4.2 to 13.3), which was slightly higher than that for chronic injuries 6.3/1000 athlete-days (95% CI 2.4 to 21.0).

    There were no severe (II° or III°) muscle or tendon injuries or joint distortions in either of the PGs, and no athlete was forced to interrupt the normal preparation schedule. Low back pain, and knee and shoulder overload were the most frequent exacerbations of chronic injuries of the musculoskeletal system in Beijing and London.

    Although during both PGs most injuries were observed in athletes with spinal cord injury, in London the actual number of injuries decreased over threefold, and IR decreased from 12/1000 athlete-days (95% CI 7.1 to 17.0) in Beijing to 4.4/1000 athlete-days (95% CI 1.1 to 7.6) in London. In all disability categories, the number of injuries and the IRs were lower in London than Beijing (table 4).

    View this table:
    Table 4

    Injuries incurred during the Beijing 2008 and London 2012 PGs by disability category

    The IR for all illnesses decreased from 49.2/1000 athlete-days (95% CI 39.2 to 59.1) in Beijing to 31.3/1000 athlete-days (95% CI 22.6 to 39.9) in London. Respiratory track infections (RTIs) were predominant in both PGs, with the same number of cases, but a higher IR in London than in Beijing: 18.1 vs 15.2/1000 athlete-days (95% CI 11.5 to 24.7 vs 9.7 to 20.7).

    In Beijing, RTI occurred most frequently among athletes with cerebral palsy and amputees, while in London among athletes with spinal cord injury, in both PGs, RTI occurred least frequently in visually impaired athletes.

    Disorders of the digestive system occurred less frequently in London than in Beijing: IR 3.1 vs 5.2/1000 athlete-days (95% CI 0.4 to 5.9 vs 2.0 to 11.8). Sleep disorders and the remaining consultations were marginal in London, though ‘other’ illnesses were the second most frequent category, both in Beijing and London, with respective IRs of 12.6 vs 6.3/1000 athlete-days (95% CI 7.5 to 17.6 vs 2.4 to 10.1).

    Both in Beijing and London, most injuries and illnesses occurred in athletes with spinal cord injury (table 5).

    View this table:
    Table 5

    Illnesses incurred during the Beijing 2008 and London 2012 PGs by disability category

    Discussion

    Before the 2008 Beijing and 2012 London PGs

    The aims of this study were: (1) to present the health status and disability category of Polish athletes before the London and Beijing PGs and (2) to compare the injuries and illnesses incurred during both PGs in view of the more stringent PHE guidelines implemented before London. The first important finding of this study is that medical care guidelines introduced before the London 2012 PGs may have had a direct impact on the staggeringly better results achieved by the Polish athletes.

    Our investigation conducted before the Beijing PGs revealed that most Polish athletes had not complied with the mandatory PHE.39 This resulted in several serious illnesses and overuse injuries in Beijing, as the athletes had dissimulated during PPE. This may have been caused by the disabled athletes’ specific approach to periodic medical examination. According to Sobiecka,22 many disabled Polish athletes adopt the avoidance strategy in the face of medical check-ups. Once nominated for the PGs, out of fear of being disqualified on health-related grounds, the athletes sometimes choose not to report existing symptoms. This situation may largely be caused by the absence of systematic medical care, replaced by ad hoc pre-PGs check-ups.22 ,45–48 Our observations of the athletes’ behaviour in Beijing during the first days in the Paralympic village confirm this. Unbeknown to their own medical team, the athletes reported directly to the Paralympic polyclinic, where they were diagnosed and treated for previously undisclosed illnesses. Reynolds et al2 made a similar observation regarding British athletes, who immediately on arrival in the Paralympic village, en masse, reported pre-existing illnesses. As a result, more attention has since been paid to improving the Paralympic pre-participation medical examination and making specialist medical care more easily accessible.

    The presented experience regarding Polish athletes in Beijing, the absence of continuous medical care in the period between the summer PGs (Athens vs Beijing)46–48 and winter PGs (Vancouver vs Turin),49 as well as the absence of systematic PPE, all called for a more rigorous enforcement of PHE execution.40 The more stringent rules of the subsequent PPE carried out by the Chief of the medical mission before the London PGs confirmed compliance with the requirement to carry out multispecialist PHE, laboratory tests and follow-up examinations. It would seem that the enforcement of PHE as a prerequisite to PGs participation brought excellent results in London. There was only one instance of polyclinic consultation unbeknown to the medical team by an athlete wishing to verify the diagnosis made at the Polish mission outpatient clinic. A single case of exacerbation was observed during the PGs as a result of earlier dissimulation.

    During the 2008 Beijing and 2012 London PGs

    The second important finding of this study is that acute injuries were less frequent in London. The IR of chronic injuries was similar in both PGs, while the IR of acute injuries was lower in London. RTIs were predominant in Polish athletes both in Beijing and in London. Although the number of infections remained unchanged in both PGs, the IR of RTI in London was slightly higher: 18.1 vs 15.2/athlete-days (95% CI 11.5 to 24.7 vs 9.7 to 20.71). This confirms the importance of prophylaxis, as RTIs can seriously limit exercise capacity.

    The medical care athletes receive differs from country to country and medical examinations are sometimes conducted during preparation camps.15 However, this kind of clinical evaluation has limited diagnostic possibilities. The implementation and compliance with the International Olympic Committee's (IOC's) recommendations on medical examinations7 leave a lot to be desired. The International Paralympic Committee (IPC) has not as yet expressed its opinion in this regard, other than recommending healthcare monitoring during PGs,16–20 mostly focusing on the epidemiology of injuries and illnesses.50–52

    The absence of methodology on collecting surveillance data in existing papers22 ,23 and the current paucity of data regarding injuries and illnesses compliant with the IOC surveillance approach make an in-depth analysis of changes over time and between countries impossible. Although the presented study is a single-nation analysis, we believe that the identified key aspects are not solely of local importance, but may prove universally applicable.

    Injuries and illnesses by disability category

    The third important finding, both in Beijing and in London, was that athletes with spinal cord injury had the highest IR of injuries and illnesses. To the best of our knowledge, our report is the first analysis of injuries and illnesses in Paralympians by disability category. The increased predisposition to injuries and illnesses originates from the actual disability and thus from the character of the dysfunction and the risk of complications. Our results showed that athletes with spinal cord injury had the highest IR of injuries: 12 in Beijing versus 4.4 in London/1000 athlete-days (95% CI 7.1 to 17.0 vs 1.1 to 7.6) and of illnesses: 16.2 vs 11.9/1000 athlete-days (95% CI 5.1 to 13.8 vs 6.4 to 17.2).

    Surprisingly, in Beijing, athletes with cerebral palsy had IR 12.6/1000 athlete-days (95% CI 7.5 to 17.7) of illness-related consultations, while les autres accounted for only 1.6 (95% CI 0.0 to 3.3). Despite the fact that in London the Les Autres group was twice as big as in Beijing (27 vs 13), the number of injuries decreased (n=3), while illnesses increased (n=8). The injury IR decreased from 3.7 in Beijing to 1.9 in London/1000 athlete-days (95% CI 0.9 to 6.4 vs 0.0 to 4.0), while the illness IR increased from 1.6 to 5.0/1000 athlete-days (95% CI 0.0 to 3.3 vs 1.5 to 8.5). In London, the lowest number of injuries was observed in athletes with intellectual disability and those who were visually impaired (n=1 each), IR 0.6/1000 athlete-days. The fewest illnesses were observed in cerebral palsy and visually impaired athletes (n=4, each), IR 2.5/1000 athlete-days.

    Despite the association between some illnesses and injuries with specific disabilities, illnesses are more unpredictable and difficult to prevent than injuries and overuse of the musculoskeletal system. This may be due to the fact that a lot of attention has been paid to improving movement techniques (depending on the individual possibilities of the disabled athletes)53 and the quality of individual sports and orthopaedic equipment.54 At the same time, the simple lack of adequate hygiene among athletes (eg, travellers’ diarrhoea)55 and preventative measures (eg, jet lag)56 or health-related factors of illnesses (eg, PPE, PHE, vaccination, etc)46–49 may lead to unexpected infections or diseases.

    Our data analysis showed that most injuries and illnesses, both in London and in Beijing, were incurred by athletes with spinal cord injuries. These results, as well as the injury/illness profiles, cannot be compared with the results of other authors as there is a paucity of literature on the subject. Furthermore, owing to the small numbers of athletes representing different disability groups, it is impossible to analyse the injury/illness profiles by sports discipline and disability category. Nonetheless, it can be concluded that the injury/illness profiles of disabled and able-bodied athletes are alike.2 ,3 ,21 This may indicate a similarity between the Paralympic and Olympic level of competitiveness. Comparing the results of studies on able-bodied athletes conducted by Derman (Sydney, Athens)14 ,15 with the results of studies involving disabled athletes conducted by Sobiecka (Sydney),22 Derman and Subban (Sydney, Beijing)23 and our own results (Beijing, London), a similarity in the injury/illness percentages can be observed. The trend towards an increasing prevalence of illnesses over injuries in consecutive PGs is noticeable in the Polish Paralympic team.

    Fact or coincidence

    The considerable drop in the number of consultations during the London PGs could, at least partly, have been caused by the fact that, unlike before the Beijing PGs, all athletes underwent the obligatory multispecialist PHE before receiving Paralympic nomination.

    Still, the fact remains that whereas in Beijing Poland placed 18th with 30 medals of which only 5 were gold, in London, the Polish Paralympians placed 9th, winning 36 medals of which 14 were gold.57

    It is for the coaches and athletes themselves to answer whether the improved performance in London was a result of the more stringent medical procedure or a mere coincidence.

    Conclusions

    • Illnesses were more frequent than injuries in disabled athletes.

    • In Beijing, chronic injuries were more frequent than acute injuries; in London, they were less frequent.

    • Respiratory tract infections presented a serious problem.

    • There were no severe muscle/tendon injuries or joint distortions.

    • Some groups of disabled athletes with spinal cord injuries are at an increased risk of injuries and illnesses.

    • PHE confirmed the importance of regular prophylactic multispecialist medical examinations.

    What are the new findings?

    • The more stringent medical care guidelines implemented before the London 2012 Paralympic Games may have had a direct impact on the staggeringly better results achieved by the Polish athletes.

    • Athletes with spinal cord injury had the highest incidence rate of injuries and illnesses.

    Acknowledgments

    The authors would like to thank Sandra K Lindon for the proofreading of this manuscript.

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    Footnotes

    • Contributors WG is the guarantor and takes full responsibility for the finished article. He was involved in the study design, data collection, statistical analysis, data interpretation, manuscript preparation and literature search. JS contributed to the data collection, statistical analysis, data interpretation and literature search. JM contributed to the data collection.

    • Competing interests None.

    • Patient consent Obtained.

    • Ethics approval Ehical approval was obtained from the Bioethics Committee at the District Medical Chamber in Kraków, Poland.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • ▸ References to this paper are available online at http://bjsm.bmj.com