The physio and the disabled athlete: separating fact from fiction

In this two-part series, Andrew Hamilton and Sean Fyfe provide an insight into working with disabled athletes and how therapists can best care for athletes with a disability.

Although public perception is changing, the stigma of disability in sport remains. Disabled athletes at all levels, right up to Paralympians are all too often regarded by the general public as curiosities or even as objects of pity – rather than sportsmen and women who love to train hard and compete, but who also happen to have a disability. Much of this of course is down to ignorance, where the differences between able-bodied and disabled athletes are seen as more important than the physiological similarities. The research however tells us that disabled athletes can benefit just as much from vigorous activity and competition, and push themselves just as hard as able-bodied individuals.

In a very recently published study on exercise guidelines for adults with spinal cord injury, researchers conducted a systematic review of relevant literature and held three consensus panel meetings (European, Canadian and International) to establish recommended exercise protocols(1). They concluded that for optimum cardiorespiratory fitness and muscle strength benefits, adults with a spinal cord injury should engage in at least 20 minutes of moderate-to-vigorous intensity aerobic exercise two times per week AND that they should also perform three sets of strength exercises for each major functioning muscle group, at a moderate-to-vigorous intensity, two times per week. This latter recommendation was highlighted as being particularly important. Keep in mind that these parameters are in addition to normal activity and serve as minimums for baseline health.

These recommendations fit with previous evidence that 2-3 sessions/week of upper body aerobic exercise at a moderate to vigorous intensity for 20-40 minutes, plus upper body strength exercise (3 sets of 10 repetitions at 50%-80% 1-repetition maximum for all large muscle groups), can improve cardiorespiratory fitness, power output, and muscle strength in athletes with this type of disability(2).

The injured disabled athlete

With the recommendations that disabled athletes should be encouraged to train hard, and the inspiring sight of Paralympian heroes pursuing Olympic dreams, clinicians might expect to see an increasing number of injured, disabled athletes coming through their clinics!

While clinicians may be faced with particular challenges in terms of assessment and rehab of a disabled athlete (for example, a useful diagnostic test or an effective rehab technique that may not be suitable as it involves a non-functioning muscle group/limb), this should not been seen as an inherent problem. That’s because research suggests that although there may be additional physical barriers to overcome, disabled athletes – particularly those participating at elite levels – may possess mental attributes that more than make up (see box 1).

Box 1: Mental toughness

Mental toughness is a quality that sports psychologists have studied in depth – because good evidence suggests that it is highly correlated with success in sport(3). There’s no universal definition of mental toughness in sport; however, an individual who continues to persevere and achieve their goals in situations so adverse they would ordinarily be expected to falter and fail, would almost ubiquitously be described as demonstrating mentally tough behaviour(4).

Why does mental toughness correlate with sport success? This is most likely because transient exposure to adversity is now considered to be an important formative experience for talent development – so-called ‘post-traumatic growth’ (PTG). In studies of athletes, sports-based traumas such as severe injuries were universally viewed as negative experiences at the time, but were retrospectively seen by the athletes as having had a positive impact on their future development(5).

One group of athletes that exemplify PTG is Paralympic athletes. Paralympic athletes constantly have to deal with: sport overuse, risk behavior, functional limitations, psychological stressors, normalised pain, health hazards, and unequal prerequisites(6). Relative to able-bodied athletes, research suggests that athletes with disabilities demonstrate stronger resiliency and self-efficacy skills than able-bodied athletes(7). In short, they tend to be extremely mentally tough.

Implications for the clinician

The study of best sports science practice for disabled athletes such as Paralympians is still in its infancy. What is known however is that disabled athletes are often capable of sustaining high training loads, which means they are likely to require the input from a clinician at some point in their sporting career. Indeed, there’s solid evidence that certain categories of disabled athletes may be particularly susceptible to injury.

For example, a 2017 study of wheelchair athletes found a relatively high prevalence of shoulder complaints, ranging from 16% to 76%(8). Pain was found to be a common, and researchers found that the cause of shoulder problems was difficult to identify and likely multifactorial, with increased years of disability, age and BMI all increasing risk.

In another study, 139 elite athletes with physical disabilities completed a questionnaire about sports-related injuries that resulted in at least one day off from training or competition(9). All disability groups sustained soft tissue injuries in high percentages. Cerebral palsy athletes reported soft tissue injuries and lacerations in higher percentage than other disabled athletes and spinal cord injured athletes. Spinal cord injured athletes meanwhile sustained fractures and blisters in higher percentages than the other groups.

A further study by German researchers published last year analysed the finding of the German Medical team caring for the German Paralympians at the 2016 Rio Olympics(10). A total of 201 musculoskeletal complaints were recorded for 140 athletes (93.3%), corresponding to 1.4 musculoskeletal complaints per injured athlete. The incidence of musculoskeletal complaints in German athletes was 62.9 per 1000 athlete-days. High incidence rates were observed in wheelchair basketball (72/1000 athlete-days, 1.6 injuries per athlete) and equestrian events (72.7/1000, 1.6). Musculoskeletal complaints were mainly located in the upper extremities (37.6%) and the spine (37.6%). The most frequent diagnoses were myalgia.

Overcoming any challenge

The scope of disabilities experienced by  parathletes is vast. People are limited only by their own beliefs, therefore, never write off an athlete. Runners, skiers, and tennis players will have similar rehabilitation needs no matter how they appear on the field of play, and yet their disability may require some unique problem solving to help accomplish their rehab goals.

IAAF World ParaAthletics Championships 2017 Namibia’s Lahja Ishitile after the Women’s 400m

IAAF World ParaAthletics Championships – 2017 Kenya’s Priscah Jepkemei (R) with her guide before the start of the Women’s 400m









Tough clients

The limited evidence to date suggests that (per athlete-hour of training), elite disabled athletes are at a greater risk of injury than their able-bodied contemporaries. For these athletes (and clinicians) however, the quality ‘mental toughness’ alluded to above shouldn’t be underestimated. Disabled athletes, particularly at the elite level, will have already overcome seemingly insurmountable obstacles. This quality will work in their favour during any rehab protocol, and is something that should be borne in mind by the clinician when prescribing exercise therapy. Although the rehab of an injured disabled athlete is something of a challenge, you should relish it because there’s every chance your client will!


  1. Spinal Cord. 2018 Apr;56(4):308-321
  2. Neurology. 2017 Aug 15;89(7):736-745
  3. Psychol. Sport Exerc. 2015; 16 37–48
  4. Front Psychol. 2017; 8: 1270
  5. J. Appl. Sport Psychol. 2016; 29 101–117
  6. Eur. J. Sport Sci. 2016; 16 1240–1249
  7. J. Clin. Sport Psychol. 2011; 5 197–210
  8. PLoS One. 2017 Nov 21;12(11):e0188410
  9. Folia Med (Plovdiv). 2011 Jan-Mar;53(1):40-6.
  10. J Sports Med Phys Fitness. 2017 Nov;57(11):1486-1493
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