9th Annual International Stoke Mandeville Games (1960, Rome)
Paralympic sports planned for 2016–2018
IPC Alpine Skiing
IPC Cross-Country Skiing
IPC Ice Sledge Hockey
IPC Wheelchair Dance
In 1976 the Paralympic Games allowed participation of athletes with visual impairment and athletes with limb deficiency for the first time. Held in Toronto, these Games were known as the Olympiad for the Physically Disabled. In 1980 athletes with cerebral palsy and athletes with physical disabilities not fitting into the previously defined categories (Les Autres, French for “the others”) were also included in the Games, at that time called The Arnhem Summer Olympics for the Disabled. Although athletes with intellectual disabilities have participated in some Paralympic Games in the past, injuries in this athletic population will not be a focus of this chapter.
Changes in amount of individual participation impose a further complication for interpreting the available data. In the 1970s and 1980s, it was not uncommon for an individual athlete to compete in multiple sports at the Paralympic Games. For example, a survey of 128 athletes, published in 1985, found 79% of these athletes were competing in track events, 71% in wheelchair basketball, 57% in road racing, and 60% in field events . Although it was commonplace initially, this occurrence is rare in elite adaptive sports today.
Advancements in technology have also changed performance parameters and injury risk characteristics during the past two decades. Designs for wheelchairs and prostheses are quickly evolving. Lightweight, high tensile strength materials continue to improve. In addition, training protocols and access to specialized trainers, coaches, and medical personnel have progressed in the last 20 years. Subsequently, comparisons between injury patterns seen 10–20 years ago with those seen currently may not be appropriate and findings from older research articles in this area may not reflect the current environment in elite Paralympic sport.
Definition of Injury
The interpretation of study results is additionally challenging with a lack of consensus on what constitutes an injury and when it should be reported. The definitions of injuries reported vary between studies. Without fail, the definition of injury influences both the data collected and the risk assessment of the sports studied. For instance, several retrospective questionnaire studies included minor soft tissue injuries, listed as blisters or abrasions, for which no medical attention was sought. However, other research efforts, which were based on the organizing committee’s medical services at the Paralympic Games, did not include such minor soft tissue injuries.
Review of the Literature
The aim of this chapter is to review the current literature on adaptive sports epidemiology, ultimately in a quest to provide the best care for Paralympic athletes. Source material for this review were primarily published articles and reports from a literature search of PubMed and SPORTDiscus. Information was also collected and evaluated from Congressional proceedings as well as both published and unpublished articles known to the authors but not identified through these database sources. Articles published in English were used primarily, but some German texts were incorporated when translation was available. Search terms involved permutations and combinations of Paralympic, sport, disability, injury, cerebral palsy, visually impaired, and wheelchair.
The unique grouping of sports by disability in Paralympic sport is complex and makes obtaining a clear picture of injury risk difficult. There are currently 30 Paralympic sports (Table 4.1) which include 25 summer events planned for Rio 2016 and five winter events planned for PyeongChang 2018. Some sporting events such as Athletics allow participation by athletes with different impairments, including athletes with spinal cord injury, visual impairment, limb deficiency, and cerebral palsy. Other sporting events are unique to a particular disability category. For example, goalball only allows competition by athletes with visual impairment, whereas wheelchair rugby has sole participation by athletes with impairment in all four limbs. Clearly this makes investigating the risk of injury related to a particular sport for the upcoming 2016–2018 Games quite challenging. Further, some sports are modified by equipment specific to impairment such as a sledge for ice hockey. Comparatively, alpine skiing features multiple events (downhill, super-G, super combined, giant slalom, slalom, and snowboard), and its participants have options between multiple types of equipment (single ski, sit ski, or orthopedic aids) adapted to the athlete’s impairment. Some sporting events such as basketball require multiple classes of disability to be included on the same team.
Caution is also required when interpreting studies where the investigation is focused on the risks related to a particular class of disability across different sports. For example, an athlete with a lower limb deficiency may compete with a prosthesis for track athletics or cycling, without a prosthesis for swimming or high jump, or in a wheelchair for sports such as basketball and tennis. Athletes with cerebral palsy may be ambulant or wheelchair users depending upon their degree of impairment. Some more recent studies have used a combination of impairment and sport specificity to limit these confounders but so far have relatively few athlete numbers [2–4].
In order to review the literature and better understand possible patterns of injury, this chapter is broken down into three categories: location, type, and rate of injury. For the location of injury, we attempt to identify common anatomic locations prone to injury. In the type of injury, we discuss both the etiology and medical diagnosis of injury and acute versus chronic injury patterns. Whereas for the rate of injury, we review injury incidence rates divided by winter and summer sports.
Anatomic Location of Injury
Lower limb injuries are frequent in winter sports such as alpine skiing and ice sledge hockey. However, through the research efforts of the International Paralympic Committee, certain ice sledge hockey injuries have become less common following regulation changes on protective equipment and sledge height. Specifically, Webborn et al.  reported four lower limb fractures occurring in spinal cord-injured ice sledge hockey athletes during the 2002 Winter Games. After rule changes were made to improve protection, only one lower limb fracture occurred in ice sledge hockey over both the 2006 and the 2010 Winter Games combined. Interestingly, athletes in seated alpine ski racing classes consistently had more upper limb injuries than lower limb injuries in the 2002, 2006, and 2010 Winter Paralympic Games [5–7]. Injuries to the head and neck in both ice sledge hockey and alpine events were also common.
Upper limb injuries are common among wheelchair athletes and Paralympians participating in the Summer Games. The upper limb, particularly the shoulder, is the most common site of injury in studies involving athletes who compete in wheelchairs. The prevalence of shoulder injury ranges from 19%  across multiple wheelchair sports to 72% in female wheelchair basketball players . However, Webborn and Turner  noted in their report on 244 British athletes seen during a 4-week period, including the buildup to and the competition in a Summer Paralympic Games, that although the shoulder was the most common site of subjective pain in wheelchair athletes (30%), the spine was more often the actual objective site of pathology. Specifically, the cervical spine (59%) and thoracic spine (8%) were identified as the cause of shoulder pain in wheelchair athletes who presented with a chief complaint of shoulder pain, while in 33% of these athletes the shoulder was the actual site of pathology. Irrespective of impairment type and adaptive technology used, the distribution of injury by body part was greatest in the upper limb (50.2% of all injuries) during the 2012 London Summer Games  with shoulder injuries being most prominently reported location of injury (17.7% of all injuries).
Although common, an upper limb injury was not the most common injury in all sports and disability groups. When looking at a more specific athlete population, such as standing volleyball players with an impairment, shoulder injury was not the most common location of injury, thus showing variation by individual sport. Reeser  identified the foot and ankle as the most common site of injury (21%), followed by the shoulder (18%), wrist and hand (18%), and the knee (14%) in a report of injury patterns among elite disabled standing volleyball players, which involves athletes with upper and lower limb impairments including amputation. In this study, the distribution of injury locations was not related to the specific type of disability. Similarly in a 4-year study examining injury in thirteen Brazilian footballers with visual impairment , the greatest proportion of injuries reported were lower limb (80%), head (8.6%), spine (5.7%), and upper limb injuries (5.7%).
Type of Injury
Acute vs. Chronic
Table 4.2 shows the percent distribution of acute and chronic injuries reported in the literature for most winter and summer Paralympic sports with acute injuries being slightly more prevalent [1–7, 11–20]. Over all sports studied, there is a 55:45 mean ratio of acute to chronic injuries. However, there is marked variation by sport, understandably with differences seen between contact and endurance sports. Most of the injuries recorded in the injury registry for the 2002 Winter Games were of acute, traumatic onset and involved the disciplines of alpine skiing and ice sledge hockey . This variation by sport may, in part, be a function of when the injury data were collected with competition surveys reporting more acute injuries [12, 19, 21] and longitudinal surveys reporting more chronic injuries [1, 16].
Distribution of injury onset: acute vs. chronic
Type of sport
Ferrara et al. 
SC, A, LA
Webborn et al. 
SC, A, CP, LA, VI
Ice sledge hockey
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