© 2014 John Wiley & Sons A/S.

Scand J Med Sci Sports 2014: ••: ••–•• doi: 10.1111/sms.12175

Published by John Wiley & Sons Ltd

Review

Sports-related injuries in athletes with disabilities K. Fagher1, J. Lexell1,2,3 Department of Health Sciences, Lund University, Lund, Sweden, 2Department of Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden, 3The Swedish Sports Organization for the Disabled and The Swedish Paralympic Committee, Lund, Sweden Corresponding author: Kristina Fagher, RPT, MSc, Department of Health Sciences, Rehabilitation Medicine Research Group, Lund University, PO Box 157, 221 00 Lund, Sweden. Tel: +46 46 222 1991, Fax: +46 46 222 1808, E-mail: [email protected]

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Accepted for publication 9 December 2013

The number of athletes with disabilities participating in organized sports and the popularity of the Paralympic Games is steadily increasing around the world. Despite this growing interest and the fact that participation in sports places the athlete at risk for injury, there are few studies concerning injury patterns, risk factors, and prevention strategies of injuries in disabled athletes. In this systematic literature search and critical review, we summarize current knowledge of the epidemiology of sportsrelated injuries in disabled athletes and describe their characteristics, incidence, prevalence, and prevention strategies. The outcomes of interest were any injury, either an acute trauma or an overuse event. PubMed,

EMBASE, CINAHL, and Google Scholar were systematically searched and 25 of 605 identified studies met the inclusion criteria. Lower extremity injuries were more common in walking athletes, whereas upper extremity injuries were more prevalent in wheelchair athletes. The methodologies and populations varied widely between the studies. Few studies were sports or disability specific, which makes it difficult to determine specific risk factors, and few studies reported injury severity and prevention of injuries. Further longitudinal, systematic sports and disability specific studies are needed in order to identify and prevent injuries in athletes with disabilities.

Exercise is frequently associated with health benefits and is widely recommended as a proactive behavior to reduce the risk of several diseases such as osteoporosis, cardiovascular diseases, the metabolic syndrome, and cancer (Pedersen & Saltin, 2006). For a disabled person, it is even more important to be physically active to improve and maintain cardiovascular fitness, selfefficacy, and self-perceived quality of life (Blauwet & Willick, 2012). Participation in organized sports is a natural way for people with disabilities to be physically active, and the opportunities to take part in organized sports have increased markedly during the last decades. However, participation in sports also increases the risk of sports-related injuries, either acute trauma or overuse injury. An injury may lead to morbidity and mortality (Kjaer et al., 2005; Ljungqvist et al., 2009) and the individual could lose training time and working/school time. Furthermore, sports-related injuries can be a burden for the society, with medical treatment, rehabilitation, and reduced work capacity (Kjaer et al., 2005). For the disabled athlete, an injury could also have more serious consequences compared with an able-bodied athlete. For example, an upper extremity muscle strain may influence the throwing in an able-bodied javelin thrower, whereas it will affect both sports participation and activities of daily living in a disabled wheelchair javelin thrower (Vanlandewijck & Thompson, 2011). Despite the growing popularity and

interest in competitive and Paralympic sports, there has been little research on injuries caused by sports participation among disabled athletes. In a health-care perspective, Paralympic sports poses many challenges not faced in Olympic sports (Webborn & Van de Vliet, 2012). Existing studies show that the overall rates of injuries are considerably high and comparable with injury rates in able-bodied athletes. However, data regarding the epidemiology of injuries, time loss due to injury, injury severity, and sports and disability specific risk factors are very limited. Furthermore, very few studies have assessed injury prevention strategies. The aim of this systematic literature search and critical review was therefore to bring together current knowledge about injury epidemiology with a focus on prevalence, incidence, etiology, risk factors, and prevention strategies of sports-related injuries in athletes with disabilities participating in organized sports and Paralympic sports. Methods This review is based on a structured systematic literature search that was conducted in the following databases: PubMed, CINAHL, EMBASE, and Google Scholar. The first database search was completed before the 25th of April 2013 and updated on 1st of June 2013. The literature search employed the following keywords: “sports” AND “Paralympic” OR “disability” AND “wounds and

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Fagher & Lexell injuries” OR “injury” AND “epidemiology” NOT “review”. The search produced 605 results (Fig. 1). In addition, each reference list from the identified articles was cross-checked to verify that relevant articles were not missed. The same eligibility criteria were considered in the screening of titles, abstracts, and full text.

Eligibility criteria and selection process To be eligible for inclusion, each study needed to be: (a) written in English; (b) published in a peer-reviewed journal between January 1985 and June 2013; (c) include disabled athletes participating in organized sports or Paralympic sports; and (d) present adequate quantitative results. The conditions of interest were sports-related injuries, either acute injury and/or overuse injury. A total of 43 potentially relevant studies were found, assessed, and evaluated against the eligibility criteria; 28 studies were not in the area of interest, and 14 other studies were identified through other sources. Finally, 29 studies were included for detailed evaluation; four were subsequently excluded because they did not meet the eligibility criteria. Thus, 25 remaining studies are included in this review (Fig. 1).

Results Summary of search results Of the 25 included studies, 10 studies were prospective and 15 retrospective studies. Thirteen studies were older than 10 years, and 18 studies had a definition of injury. Ten studies used prevalence as outcome (9–86%), seven reported incidence rate (IR), and eight of the studies reported incidence. Fourteen studies separated the injuries as acute or nonacute, 12 reported disability-specific injuries, and 20 reported sports-specific injuries. Nine

Fig. 1. Flow chart of the literature search.

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studies reported sports and disability specific injuries together. Sports that featured most were swimming, wheelchair basketball, and athletics. No studies reported injuries in triathlon or canoe. A majority of studies reported injuries to the musculoskeletal system, i.e., injuries to the upper or lower extremities, whereas very few reported other type of injuries, such as head injuries (concussion) or injuries to the internal organs. In the following section, we start by summarizing studies describing overall injury epidemiology, then injuries specific to wheelchair athletes, injuries specifically reported during winter sports, and finally acute vs nonacute injuries. In Table 1, we present the characteristics of the 25 reviewed studies. In Fig. 2, the injuries are described by body location in the 18 studies that included these data, and in Table 2, studies reporting sports-specific injuries are presented. Overall injury epidemiology In this section, we describe the overall injury epidemiology of the reviewed studies. Lower extremity injuries appeared to be more common in walking athletes [amputees, visual impairments (VIs) and cerebral palsy (CP)] (Athanasopoulos et al., 2009; Patatoukas et al., 2011; Magno e Silva et al., 2013b, c). During the 1996 Summer Paralympic Games in Atlanta, USA, athletes with a unilateral amputation from Disabled Sports USA suffered from a higher injury frequency in the ankle region

Injuries in athletes with disabilities Table 1. Characteristics of studies and type of injuries Author, (publication year), type of study

Population, disability, sports, and follow-up Injury definition period

Results

Type of injuries

Athanasopoulos et al. (2009 Retrospective

n = nr Age: mean 31.4 years IPC impairments* Paralympic Sports† Physiotherapy Service at the Paralympic Summer Village Polyclinic 2004

nr

131 athletes reported injury

Bernardi et al. (2003) Retrospective

n = 227 Age: range 12–60 years CP, SCI, amputees, “les autres” Swimming, track and field, basketball 1 year n = 151 Age: nr IPC impairments* Paralympic Sports† Paralympic Summer Games 1988

Any muscle pain during the past 12 months during sport activity at least 1 day

Prevalence 50.7%

Acute injuries 64.1% Overuse injuries 22.1% 28.2% tendinopathy Most injuries to the upper extremity among (WA) Most injuries to the lower extremity among (VI) 56% shoulder injuries Increased prevalence rate of sports-related muscle pain with increased training volume

nr

84 injuries in 151 athletes

n = 14 Age: mean 28.6 Wheelchair athletes Wheelchair foil fencing 3 years n = 128 Age: mean 29 SCI, congenital disorders, postpolio, amputees, neuromuscular disorders Wheelchair sports; track, basketball, field, swimming, road racing nr n = 46 Age: mean 33 Female wheelchair athletes Wheelchair basketball One tournament n = 19 Age: mean 29.5 Wheelchair athletes Wheelchair; track and field, shooting, swimming, table tennis 1 year n = 426 Age: mean 25.7 Track, field, weightlifting, swimming Wheelchair users, CP, VI National Competition 1989

Trauma that occurred during a training/competition and prohibited the athlete from continuing fencing activity for at least 1 day

Incidence 3.9/1000 h

nr

Prevalence 72%

The Wheelchair User’s Shoulder Pain Index

Prevalence 52%

72% reported shoulder pain and 70% reported hand or elbow pain since start of wheelchair use

Anything the athlete expressed concern about and caused loss of participation due to injury or illness

50 injuries in 19 athletes

Any trauma to the participant that occurred during any practice, training, or competition session that caused the athlete to stop, limit, or modify participation for 1 day or more

Prevalence 32%

Any trauma to the participant that occurred during any practice, training, or competitive session that resulted in the cessation, limitation, or modification of the athlete’s participation for at least 24 h Any injury/illness that was evaluated by the U.S. medical staff during the study period

100 injuries in 68 athletes

Acute injuries 65% Overuse injuries 23% 48% strains 58% upper extremity injuries 32% of the injuries caused a time loss of 22 days or more of participation in sport Acute injuries 45.9% Overuse injuries 54.1% 44.3% upper extremity injuries The athletes with disability demonstrated approximately the same percentage of injury as the athlete without a disability in similar sports activities Acute injuries 40% Overuse injuries 60% 51% upper extremity injuries

Burnham et al. (1991) Retrospective

Chung et al. (2012) Prospective

Curtis and Dillon (1985) Retrospective

Curtis and Black (1999) Retrospective

Ferrara and Davis (1990) Retrospective

Ferrara et al. (1992a) Retrospective

Ferrara et al. (1992b) Retrospective

Ferrara et al. (2000) Prospective

Magno e Silva et al. (2013b) Prospective

Magno e Silva et al. (2013c) Prospective

Magno e Silva et al. (2013a) Prospective

n = 68 Age: mean 29.6 Amputees, SCI, VI, spina bifida, MS, muscular dystrophy Skiing Six months n = 1360 Age: nr Wheelchair users, CP, VI, dwarf Multisports 5 competitions, 6 years n = 13 Age = nr VI Blind football 4 years (5 competitions) n = 40 Age = nr VI Track and field 4 years (5 competitions) n = 28 Age = nr VI Swimming 4 year (5 competitions)

1037 injuries/1360 athletes

Acute injuries 49% Overuse injuries 51% 21.4% of all injuries classified as rotator cuff impingement High number of lower extremity injuries in (VI) 73.8% upper extremity injuries 58.9% strain Wheelchair fencers had a higher overall injury incidence rate than abled-bodied fencers 33% soft tissue injuries A high number of training hours was related to a high number of injuries

Symptom 1 day or more

Incidence 2.7 Incidence rate 0.12 Prevalence 86%

Acute injuries 67.9% Overuse injuries 20.6% 22.1% sprains The most commonly body location was thorax/spine Acute injuries 80% Overuse injuries 20% 31% contusions Most common with lower extremity injuries

Symptom 1 day or more

Incidence 0.93 Incidence rate 0.39 Prevalence 78%

Acute injuries 18% Overuse injuries 82% 26% spasm Most common with lower extremity injuries

Any injury that caused an athlete to stop, limit, or modify participation for 1 or more days.

Incidence 1.5 Incidence rate 0.3 Prevalence 64%

Acute injuries 20% Overuse injuries 80% 36.6% spasm Most common with injuries in the shoulder, 29.3%

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Fagher & Lexell Table 1. (continued) Author, (publication year), type of study

Population, disability, sports, and follow-up Injury definition period

McCormack et al. (1991) Retrospective

n = 90 Age = mean 28 SCI, amputees, CP, spina bifida, neurological and congenital disorders, WA 4 competitions, all past injuries recorded n = 60 Age = mean 32 Amputees, postpolio, VI Alpine skiing 1 day, all past injuries recorded n = 23 Age = range 22–54 Paraplegia, amputees, brain trauma, MS, arthrogryposis, vascular disease Sit skiers 1 day, all past injuries recorded n = 304 Age = -nr IPC impairments* Paralympic Sports† Summer Paralympics 1996 n = 210 Age = mean 18 Autism, emotional disturbance, mental retardation, learning disability, orthopedic disability, sensory disability Basketball, field hockey, soccer, and softball 4 seasons n = 203 Age = nr IPC impairments* Paralympic Sports† Summer Paralympics 1992 n = 139 Age: mean 32.8 SCI, postpolio, CP, amputees, “les autres” Wheelchair basketball, track and field, swimming, gym, powerlifting, wheelchair dancing, shooting 1 competition n = 114 Age: mean 27 women, 30 men VI, amputees, SCI, CP, intellectual disability Paralympic Sports† Summer Paralympics 2000 n = 53 Age: nr Wheelchair athletes Wheelchair racing 1 year n = 416 Age: mean 33.0 IPC impairments* Paralympic Sports‡ Winter Paralympics 2002 (20 days) n = 505 Age: range 19–53 IPC impairments* Paralympic Sports‡ Winter Paralympics 2010 n = 3565 Age: mean 30 IPC impairments* Paralympic Sports† Summer Paralympics 2012

McCormick (1985a) Retrospective

McCormick (1985b) Retrospective

Nyland et al. (2000) Prospective

Ramirez et al. (2009) Prospective

Reynolds et al. (1994) Retrospective

Patatoukas et al. (2011) Retrospective

Sobiecka (2005) Retrospective

Taylor and Williams (1995) Retrospective Webborn et al. (2006) Prospective

Webborn et al. (2012) Prospective

Willick et al. (2013) Prospective

Results

Type of injuries

Trauma that incurred while training, practicing, or competing in wheelchair sports

346 injuries/90 athletes

24.9% blisters Upper extremity injuries most common

nr

Incidence 2.0/1000 skiers days 23 injuries in 60 athletes Incidence 16.1/1000 skiers day 21 injuries in 23 athletes

Knee injuries most common, 17.4% Lower injury incidence compared with able-bodied athletes

Soft tissue injuries; strain, sprain, tendonitis, bursitis, contusion

254 injuries/304 athletes

Acute injuries 67% Overuse injuries 33% 20.9% shoulder injuries

Events resulting in immediate removal of the athlete from the session and medical treatment by school staff or transport to a hospital. A physical trauma that was sustained to the body region of an athlete during the injury event.

Incidence 2.0 injuries/1000 sessions played

44.7% lower extremity injuries 31.6% abrasion Athletes with autism, a history of seizure, and emotional disturbance had a higher injury rate

nr

291 team Most common with injuries in the upper members, 201 extremity and the cervical spine attended the The injury/illness profile was similar to medical center those in abled-bodied sport

Any injury that caused an athlete to stop, limit, or modify participation for 1 day or more, all injuries in athlete’s sport life included

Incidence SCI 58.9% soft tissue injuries athletes 1.47, The number of fractures significantly higher CP 0.97, other in SCI athletes disabled athletes 1.16 178 injuries in 69 athletes 125 injuries/114 Injuries to the motor system athletes

nr

nr

Most common with shoulder injuries, 33.3% Sit-skiers were eight times more likely to sustain an injury than disabled athletes not using a sit ski

Symptom 1 day or more

Prevalence 72%

Acute injuries 16% Overuse injuries 52% 52% upper extremity injuries Overuse injuries recurred more often

Any injury during the games

Prevalence 9%

Any sport-related musculoskeletal complaint that caused the athlete to seek medical attention during the study period

Incidence proportion 23.8%

Acute injuries 77% Overuse injuries 15% 32% sprains 21% resulted in time lost from participating in sport Acute injuries 41% Overuse injuries 58% Increase of injuries in Paralympic Winter games

Any sport-related musculoskeletal or Incidence rate neurological complaint prompting 12.7/1000 an athlete to seek medical attention, athlete days regardless of whether or not the Injury proportion complaint resulted in lost time from 17.8/100 training or competition athletes

Acute injuries 51.5 Overuse injuries 31.8 Acute on chronic 16.7% 50.2% upper extremity injuries Higher injury rates in older athletes

*IPC impairments: impaired muscle power, impaired passive range of movement, limb deficiency, leg length difference, hypertonia, ataxia, athetosis, short stature, vision impairment, and intellectual impairment. † Paralympic Summer Sports (until 2012): football 5-a-side, powerlifting, goalball, wheelchair fencing, wheelchair rugby, athletics, judo, wheelchair tennis, table tennis, wheelchair basketball, football 7-a-side, seated volleyball, cycling track, equestrian, swimming, archery, boccia, cycling road, sailing, rowing, and shooting. ‡ Paralympic Winter Sports: alpine skiing, biathlon, cross-country skiing, wheelchair curling, ice sledge hockey. CP, cerebral palsy; MS, multiple sclerosis; nr, not reported; SCI, spinal cord injury; VI, vision impairment; WA, wheelchair athletes.

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Injuries in athletes with disabilities

Fig. 2. Injuries presented by body location in the 18 studies that included these data. Data are presented as minimum and maximum, and range.

compared with other categories of athletes (Nyland et al., 2000). A limitation of this prospective study is that only soft tissue injuries were reported (Table 1). Magno e Silva et al. (2013b) reported an injury prevalence of 84.6% in a population of 13 male Brazilian soccer players with VI during five major competitions; the clinical incidence was 2.7 injuries per athlete. The most common injuries were contusions and sprains, and 80% of the injuries were acute. The most common injury site was the lower limb (80%), and 29% of the injuries occurred in the knee. A limitation of this longitudinal study is that injuries were only reported during competitions. Similar injury patterns were seen in the Union of European Football Associations (UEFA) injury study in able-bodied soccer players, where 87% of the injuries occurred in the lower extremity and 81% resulted from trauma. On average, each player suffered from 2.0 injuries/season (Ekstrand et al., 2011).

Table 2. Studies reporting sports-specific injuries in current Paralympic Summer and Winter sports

Summer sports

Studies

Winter sports

Studies

Archery

Reynolds et al. (1994); Willick et al. (2013)

Alpine skiing

McCormick (1985a, b); McCormack et al. (1991); Webborn et al. 2006; 2012) Webborn et al. (2012) Webborn et al. 2006; 2012)

Athletics

Athanasopoulos et al. (2009); Bernardi et al. (2003); Curtis and Dillon (1985); Ferrara and Davis (1990); Magno e Silva et al. (2013c); McCormack et al. (1991); Patatoukas et al. (2011); Reynolds et al. (1994); Taylor and Williams (1995); Willick et al. (2013) Canoe – Cycling Athanasopoulos et al. (2009); Reynolds et al. (1994); Willick et al. (2013) Equestrian Athanasopoulos et al. (2009); Willick et al. (2013) Football 5-a-side Magno e Silva et al. (2013b); Willick et al. (2013) Football 7-a-side Reynolds et al. (1994); Willick et al. (2013) Goalball Athanasopoulos et al. (2009); Willick et al. (2013) Wheelchair dance Patatoukas et al. (2011) sport Judo Athanasopoulos et al. (2009); Reynolds et al. (1994); Willick et al. (2013) Powerlifting/ Athanasopoulos et al. (2009); McCormack et al. (1991); weightlifting Patatoukas et al. (2011); Reynolds et al. (1994); Willick et al. (2013) Rowing Willick et al. (2013) Sailing Willick et al. (2013) Shooting Patatoukas et al. (2011); Reynolds et al. (1994); Willick et al. (2013) Volleyball Athanasopoulos et al. (2009); Reynolds et al. (1994); Willick et al. (2013) Swimming Athanasopoulos et al. (2009); Bernardi et al. (2003); Ferrara and Davis (1990); Magno e Silva et al. (2013a); Reynolds et al. (1994); McCormack et al. (1991); Patatoukas et al. (2011); Willick et al. (2013) Table tennis Athanasopoulos et al. (2009); Reynolds et al. (1994); Willick et al. (2013) Triathlon – Wheelchair Athanasopoulos et al. (2009); Bernardi et al. (2003); basketball Curtis and Dillon (1985); Curtis and Black (1999); McCormack et al. (1991); Patatoukas et al. (2011); Reynolds et al. (1994); Willick et al. (2013) Wheelchair Athanasopoulos et al. (2009); Chung et al. (2012); fencing Reynolds et al. (1994); Willick et al. (2013) Wheelchair rugby McCormack et al. (1991); Willick et al. (2013) Wheelchair tennis Athanasopoulos et al. (2009); Curtis and Dillon (1985), Reynolds et al. (1994); Willick et al. (2013)

Biathlon Cross-country skiing Ice sledge hockey Webborn et al. 2006; 2012) Wheelchair curling Webborn et al. (2012)

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Fagher & Lexell During the 2012 Summer Paralympic Games in London, UK, a prospective injury surveillance system was used. Football 5-a-side had the highest injury IR with 22.4 injuries/1000-athletes days (overall IR 12.7); 54% of the injuries were acute. Football 7-a-side had a lower IR (11.2); 73% of these injuries were classified as acute (Willick et al., 2013). Goalball had the second highest injury IR (19.5); 77% of the injuries were classified as acute. Sports specificity, age, gender, and disability classification were included as baseline covariates in the study from the 2012 Paralympic Games, and it is recommended that future studies follow a similar approach. Another strength of this study is the reporting of incidence proportions and IRs based on exposure. However, disabilityspecific injuries were not reported (Willick et al., 2013). In a retrospective survey of 426 competitive disabled athletes in the United States, a high number of the lower extremity injuries occurred in ambulatory athletes with polio. In CP athletes, the knee (21%) was the most vulnerable and injured body part. Also, VI athletes had a high percentage of lower extremity injuries (53%), and the leg/ankle was involved in 26% of all injuries (Ferrara et al., 1992a). Soccer had the highest IR (3.7 injuries per 1000 athlete exposure) in a population of 210 athletes participating in organized high school sport in the United States; 44.7% were lower extremity injuries and athletes with autism, a history of seizure and emotional disturbance had a higher injury rate. The athletes were followed during one season (Ramirez et al., 2009). Magno e Silva et al. (2013c) documented injuries longitudinally during five major competitions in a population of 40 Brazilian track and field athletes with VI, giving a prevalence of 78% and a clinical incidence of 1.93 injuries per athlete. The most frequently reported diagnoses were spasms and tendinopathies, and 82% of the injuries occurred in the lower limbs (Magno e Silva et al., 2013c). Also Athanasopoulos et al. (2009) reported a high injury prevalence in track and field athletes. Over half (51.2%) of the total number of injuries that were admitted to the physiotherapy department of the 2004 Summer Paralympic Village Polyclinic in Athens, Greece, occurred among track and field athletes. Most of these injuries (22.1%) occurred in VI athletes. Lower extremity injuries were more common than injuries to the upper extremities in athletes with VI, CP, and amputation. The documentation of injuries was based on the physiotherapy treatment reports, and a limitation of the study is that no definition of injury was present. During the 2012 London Paralympic Games, 216 injuries were reported in the 977 athletes participating in track and field. The IR was 15.8 injuries/1000 athletesdays (overall IR 12.7), and 50% of the injuries had an acute onset, whereas 21% were acute on chronic and 29% were overuse injuries (Willick et al., 2013). At the 1992 Summer Paralympic Games in Barcelona, Spain, 80% of the track and field athletes in the British team suffered from an injury (Reynolds et al., 1994).

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However, this study has a poor description of method and injury definition. Patatoukas et al. (2011) showed in a retrospective survey that a population of Greek elite athletes with locomotor disabilities participating in standing track and field events had the second highest percentage of injury (23.0%) among nine different sports (41 injuries were reported in 35 athletes). Burnham et al. (1991) showed in a retrospective cohort study that athletes involved in stand-up track events, long jump, and high jump had a significantly higher frequency of lower extremity injuries during the 1988 Paralympic Games in Seoul, South Korea, compared with athletes involved in sports using predominantly their upper extremity. Swimming had a lower injury IR (8.7) compared with the overall injury IR (12.7) during the 2012 London Paralympic Games; 47% of the injuries were classified as acute, whereas 37% were overuse injuries and 16% were acute on chronic injuries (Willick et al., 2013). During the Summer Paralympic Games 1992 in Barcelona, 69% of the swimmers in the British team reported an injury during the games (Reynolds et al., 1994). McCormack et al. (1991) reported that wheelchair swimmers had one of the lowest injury frequencies (1.2%) in a population of 90 wheelchair athletes. Patatoukas et al. (2011) reported 34 injuries in 51 swimmers in their study among Greek elite athletes, and swimming had the third largest injury prevalence (19.1%). Magno e Silva et al. (2013a) reported a prevalence of 64.3% and a clinical incidence of 1.5 in a prospective study among a population of 28 VI swimmers; 80% of the injuries were overuse injuries, and the most affected body part was the shoulder (29.3%). Taken together, lower extremity injuries are common in walking athletes, especially in those with VI and in those participating in ball sports and track and field, and the prevalence of injuries in swimming seems to vary. However, it is difficult to compare the results as most studies have used different rate denominators and definitions of injury. Wheelchair athletes Wheelchair sports are specific to disabled athletes, and the epidemiology of injuries occurring in these types of sports are also specific to this population of athletes. Taylor and Williams (1995) reported an injury prevalence of 72% during a 12-month period in a retrospective study among a population of 53 British wheelchair racing athletes, where the most common disability was spinal cord injury (SCI) (56%). Mostly, upper extremity injuries were reported; 27% occurred in the hand and wrist followed by 25% in the upper arm and shoulder. Fifty injuries were reported in a population of 19 U.S. elite wheelchair athletes participating in track and field, swimming, table tennis, and shooting (Ferrara & Davis, 1990). In this retrospective study, a total of 60% of the injuries occurred in track and field, and 48% occurred

Injuries in athletes with disabilities during the competitive season. The most common type of injury was strain (48%), and the most frequently injured area was the shoulder (27.6%). The authors concluded that the time loss factor appeared to be higher for major injuries when compared with athletes without disability. Only time-loss injuries were recorded, and the results may therefore be biased. Curtis and Dillon (1985) retrospectively assessed the injury prevalence of 128 U.S. wheelchair athletes. The most common disability was SCI, and the largest percentage of athletes were involved in track and field (79%) followed by basketball and swimming. As many as 72% of the athletes reported that they had been injured at some time during their career. Soft tissue injuries in shoulders, elbows, and wrists were the most frequently reported injuries. The sports associated with the highest injury prevalence were track and field (26%) and basketball (24%). A significantly high proportion of injuries were reported in athletes aged 21–30 years. Noteworthy is the low response rate – the questionnaire was distributed to 1200 athletes (response rate just over 10%) – as well as the possibility of recall bias. Ferrara et al. (1992a), also in a retrospective survey, reported that the upper extremity was involved in injuries twice as often as the lower extremity in athletes from the U.S. National Wheelchair Athletics Association. A limitation of this study is that only traumatic injuries were registered. During the Summer Paralympic Games 2004 in Athens, the majority of injuries reported to the Paralympic Village Physiotherapy Service occurred among wheelchair athletes (51.2%). The most common injury site in the 67 injured wheelchair athletes was in the shoulder (50.1%) and spine (20.1%) (Athanasopoulos et al., 2009). During the same games, athletes from the Wheelchair Sports USA had a higher frequency of elbow, forearm, and wrist injuries than other categories. However, wheelchair athletes had not a higher frequency of shoulder injuries compared with other groups (Nyland et al., 2000). Also, during the 2012 London Paralympic Games, wheelchair athletes had high injury rates. Wheelchair rugby (IR 16.3) and wheelchair tennis (IR12.8) had higher injury IRs than the overall injury IR (12.7). Upper extremity injuries were the most common during the 2012 London Games (Willick et al., 2013). McCormack et al. (1991) retrospectively surveyed 90 Canadian wheelchair athletes participating in 18 different wheelchair sports. In total, 346 injuries were reported. Upper extremity injuries were the most common, and the authors suggested that the high frequency of upper extremity injuries were probably due to wheelchair propulsion. A limitation of this study is that just trauma-related injuries were registered. Curtis and Black (1999) showed in a retrospective study that 52% of a population of female wheelchair basketball players suffered from current shoulder pain during a tournament. A total of 70% of the athletes reported a history of elbow or hand pain after beginning with wheelchair driving, and 72% had a history of shoulder pain. The athletes

participated in sports and leisure activities on average 11 h per week. A limitation of this study is that just injuries to the upper extremity were recorded. During the 2012 London Summer Paralympic Games, 34 injuries were reported in 202 wheelchair basketball athletes (IR 12.0, overall IR 12.7) and 65% of these injuries had an acute onset (Willick et al., 2013). During the Summer Paralympics 1992 in Barcelona, Spain, 79% of the British basketball team players suffered from an injury (Reynolds et al., 1994). McCormack et al. (1991) reported that wheelchair basketball players were the athletes with the highest injury frequency (30.9%) in a group of 90 Canadian wheelchair athletes, and upper extremity injuries were the most common. Also, Patatoukas et al. (2011) showed that wheelchair basketball was the sport with the highest percentage of injury (30.9) among a group of Greek elite athletes. Chung et al. (2012) demonstrated in a prospective study that wheelchair foil fencers had a higher overall IR (3.9/1000 h) compared with able-bodied fencers (2.4/ 1000 h). Furthermore, wheelchair athletes without active trunk control were more susceptible to injury (4.9/ 1000 h) compared with athletes with good trunk control (3.0/1000 h). The most prevalent injuries in the wheelchair athletes were upper extremity injuries (73.8%), whereas the able-bodied fencers had a higher percentage of lower extremity injuries. Four of the 14 wheelchair fencers were absent from their sport for more than 22 days because of a major injury. Willick et al. (2013) reported an injury IR of 18.0 injuries/athletes-days (overall IR 12.7) in wheelchair fencing during the 2012 London Paralympic Games; 58% of the injuries were overuse injuries. During the Paralympic Games 1992, 71% of the fencers suffered from injury in the British team (Reynolds et al., 1994). In summary, mostly upper extremity injuries, especially in the shoulder, are reported in wheelchair athletes, confirming that these types of injuries are overrepresented among these athletes. Once again, different rate denominators and definitions of injury cause inconsistencies in the reported data and comparisons of results are therefore difficult. Winter sports Five sports – alpine skiing, biathlon, cross-country skiing, ice sledge hockey, and wheelchair curling – are included in the Winter Paralympic Games. During the 2002 Winter Paralympic Games in Salt Lake City, USA, the International Paralympic Committee (IPC) started prospective injury surveillances. Alpine skiers were the athletes that experienced most injuries (62% of all injuries), and 12.3% of all alpine skiers (n = 194) suffered from at least one injury. The most serious injuries reported were anterior cruciate ligament ruptures, distal radius fractures, and concussions. One of the conclusions of the 2002 injury surveillance was that a risk

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Fagher & Lexell factor for injury in alpine skiing may be failure of skibindings to release (Webborn et al., 2006). During the 2010 Winter Paralympic Games in Vancouver, Canada, alpine skiing had the second highest injury incidence proportion (21.6%). The sitting class athletes had a higher injury rate with 1.7 injuries/100 race exposures compared with 0.7 injuries/100 race exposures in VI athletes and standing class athletes (Webborn et al., 2012). Ferrara et al. (1992b) reported 100 time-loss injuries in a retrospective study in 68 skiers prior to the National Games of Handicapped Sports and Blind Athletes in the United States 1989. Upper extremity injuries were 1.4 times more common than lower extremity injuries; 60% of the injuries were classified as chronic. The shoulder (30%) was the most vulnerable body location, and acute injuries were most prevalent in the thigh and knee (30%). A limitation of this study is that only traumas were recorded. An IR of two injuries per 1000 skier-days was reported in a population of disabled alpine skiers in the United States; 23 injuries were reported in 60 athletes, mostly amputees. The knee (17.4%) was the most commonly injured body location, and 21.6% of the injuries were fractures (McCormick, 1985a). A higher IR (16.1 injuries per 1000 skier-days) was shown in a similar study including 23 disabled sit-skiers. Individuals with SCI at T6 or above had a higher injury frequency compared with those with paraplegia. Upper extremity injuries were the most frequently reported injuries (McCormick, 1985b). Both studies were retrospective and did not report any definition of injury. Ice sledge hockey players had the highest rate of injury per 100 athletes (14%) during the 2002 Winter Paralympic Games. Four of the injuries occurred from collisions that resulted in lower limb injuries (Webborn et al., 2006). Also, during the 2010 Winter Paralympic Games, ice sledge hockey had the highest incidence proportion (33.9%) of all sports. A total of 40 of 118 athletes required medical attention for musculoskeletal problems. Of these, 60% of the injuries were classified as overuse injuries, 52.5% of the injuries occurred during competition time and 42.9 of these, in turn, were contact injuries. Upper extremity injuries were most common (47.5%), followed by spine-related injuries (35%) (Webborn et al., 2012). Very few injuries were reported among the 134 athletes competing in the Nordic Skiing during the 2002 Paralympic Games. Three injuries were reported, all involving the upper limbs (Webborn et al., 2006). A large increase in injury prevalence was seen during the Winter Paralympic Games 2010; 26 injuries were reported in 140 athletes resulting in an injury prevalence of 18.6%. Almost half (46.2%) of the injuries were classified as acute, including serious injuries like concussions, pneumothorax, and fractures. VI athletes had a higher IR based on a new acute injury (two injuries/100 race exposures) compared with (1.3 injuries/100 race exposures) for standing class athletes (Webborn et al., 2012).

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Interestingly, a remarkable increase in injury incidence proportion was seen during the 2010 Paralympic Winter Games (IP = 23.8%) compared with the Winter Games 2002 (IP = 9.4%), and a noteworthy high prevalence (57.5%) of overuse injuries was reported 2010. The authors suggested that the high number of overuse injuries might be due to an increased level of training during the preceding years (Webborn et al., 2012). In conclusion, the reported injury prevalence in Paralympic Winter sports appears to vary. Injuries are reported both to the lower and upper extremities and seem to have both acute and chronic onset. Acute vs nonacute injuries Overuse injuries have lately gained increased attention in the literature of sports injury epidemiology. These injuries are frequently seen in sports involving repetitive movements and could lead to devastating consequences for the athlete. The mechanisms of injury are often a result of repeated micro-trauma to the tissue, with no single identifiable incident responsible for injury (Fuller et al., 2006). Clarsen et al. (2013) showed that overuse injuries represented 49% of all health problems (acute injuries 13%) in 116 Norwegian Olympic and 26 Paralympic athletes preparing for the 2012 Summer Olympic/Paralympic Games. This study is one of few prospective studies reporting injuries during normal training and not only competition. During the Winter Paralympic Games 2010, 57.5% of the injuries were overuse injuries (Webborn et al., 2012). Magno e Silva et al. (2013c) reported that 82% of the injuries, mostly in the lower extremity, were overuse injuries in their study of VI track and field athletes. Similar results have been demonstrated in able-bodied track and field athletes. Jacobsson et al. (2013) reported that 96% of the injuries were nontraumatic, and 77% of the injuries were related to the lower extremity in a population of able-bodied elite track and field athletes in Sweden. In another study of VI swimmers, 80% of the injuries were classified as overuse injuries (Magno e Silva et al., 2013a). Also, Taylor and Williams (1995) reported a high prevalence of overuse injuries in wheelchair athletes. Overuse injuries were more likely to recur within 12 months, especially in those who started their training before the pain of the injury had disappeared. In wheelchair racing athletes, 43% reported that they restarted training before the pain had disappeared, and 71% of the injuries prevented the athlete from training (the median time off training was 14 days). The authors suggested that there is a link between overuse injuries, restarting exercise before pain has disappeared and the rate of recurrence of injury. In a population of 227 Italian athletes with locomotor disability, 51% experienced sports-related muscle pain that occurred during sports activity causing discomfort for at least 1 day. A training volume above 7 h per week [odds ratio 3.8; 95% confidence interval (1.4-10.0)] was associated with pain (Bernardi et al., 2003). It has been suggested

Injuries in athletes with disabilities that there is a risk that the demands of sports activities together with daily wheelchair pushing result in insufficient time for rest and recovery of the musculature in wheelchair athletes (Curtis & Black, 1999; Ferrara et al., 2000). Curtis and Dillon (1985) showed with time exposure data that a high number of hours per week spent on training were associated with significantly higher injury prevalence. Athletes who reported most injuries were those involved in repetitive wheelchair pushing. These results might be related to overuse of soft tissue structures. Regarding traumatic injuries, Webborn et al. (2006) reported that 77% of all injuries during the Winter Paralympic Games 2002, Vancouver, were acute injuries. During the 2012 Summer Paralympic Games in London, 51.5% of the injuries were classified as traumatic injuries. Boccia had the highest proportion of acute traumatic injuries (91%), followed by goalball (77%). Also wheelchair rugby, football 7-a-side, seated volleyball, and football 5-a-side had high proportions of acute injuries (Willick et al., 2013). Ferrara et al. (2000) demonstrated that 65% of the injuries were acute in a population of elite wheelchair athletes; 32% of the injuries were classified as major (missing 22 days or more). In a longitudinal study following disabled U.S. athletes over five international competitions, including the Summer Paralympic Games 1992 and 1996, the authors recorded 1037 injuries in a total of 1360 participants; 67.9% of these were classified as acute injuries. Most of the injuries occurred during the Summer Paralympic Games 1992 (37.3%) and 1996 (39.2%). Wheelchair athletes had the highest injury prevalence (27.8%) followed by CP athletes (24.3%). The most commonly injured body part was the thorax/spine. Athanasopoulos et al. (2009) reported that 64.1% of all registered injuries at the physiotherapy department of the Summer Paralympic Games, Athens, 2004, were classified as an acute injury. Similar patterns were seen in U.S. Paralympic athletes during the 1996 Summer Games, Atlanta, where 67% (170/254) of all soft tissue injuries among 304 athletes had an acute onset (Nyland et al., 2000). Chung et al. (2012) showed that the injury IR was significantly higher during competition than training (5.1/1000 h vs 2.0/1000 h) in elite wheelchair fencers. Ferrara et al. (2000) suggested that the nature of competitive events increases the incidence of acute injuries, and a limitation of some of the reviewed studies is that injuries are just reported during competition (Table 1). In the UEFA injury study of soccer injuries in able-bodied athletes, the authors showed that 57% of the injuries occurred during matches and 43% during training. Overuse injuries were more frequent during the preseason, and traumatic injuries were more common during the competitive season (Ekstrand et al., 2011). A strength of the study by Clarsen et al. (2013), in which a web-based prospective monitoring of illness and injury in Norwegian elite athletes was performed, is that injuries were recorded both during training and competi-

tion. The conclusion of this study is that this method was sensitive and valid for recording injuries in a large group. The authors also suggested that weekly reporting may lead to earlier and more comprehensive interventions of health issues. A limitation of this study is, however, the small number of Paralympic athletes surveyed. In summary, a considerably high prevalence of sportsrelated overuse injuries has been demonstrated in athletes with disabilities. Two studies have shown that a high number of hours per week spent on training are associated with higher injury prevalence. Overuse injuries may be under-diagnosed, as some studies just include events related to trauma and competition in their injury definitions (Table 1). Several authors have reported a high number of acute injuries during competition, and it seems like athletes participating in ball sports are more prone to acute injuries. Risk factors and prevention of injuries In the sport medicine research area, preventative strategies have gained increased interest over the past years. Waldén et al. (2012) showed that anterior cruciate ligament injuries could be reduced by 64% when implementing a preventative training program in female soccer players. Van Beijsterveldt et al. (2013), however, reported conflicting evidence for the effectiveness of exercise-based programs to prevent soccer injuries and recommended high-quality studies investigating the best type and intensity of exercises. A limitation is that very few studies involving clinical trials exist within Paralympic sports. Already in 1985, Curtis and Dillon (1985) suggested that preventive strategies should be taken to decrease injury risks in disability sports. Ferrara and Davis (1990) reported the importance of designing prevention programs including strength, endurance, and flexibility for disabled athletes, and Curtis and Black (1999) recommended that warm-up strategies, stretching, and strengthening should be included in the training. McCormick (1985a) suggested focusing on strengthening of the legs, improvement of cardiovascular fitness, and adequate equipment to help reduce the injury rate among disabled skiers. Bernardi et al. (2003) showed that a high training volume was associated with sportsrelated muscle pain in disabled athletes, and monitoring of training volume was suggested as part of injury prevention. Also, the authors of the injury surveillance study during the 2012 Paralympic Games recommended that injury prevention interventions should initially target high risk sports (Willick et al., 2013). According to the model that van Mechelen et al. (1992) presented for prevention of sports injuries, the first step is to evaluate the extent of the injury problem through injury surveillance. Thereafter, injury risk factors and injury mechanisms could be established, and on the basis of this information preventive strategies can be introduced. Risk factors for sports injuries are often classified as intrinsic or extrinsic. Intrinsic risk factors

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Fagher & Lexell are related to the athlete, whereas extrinsic risk factors are related to the environment. In disabled athletes, the disability itself could be considered an intrinsic risk factor (Magno e Silva et al., 2013a). For example, during the Paralympic Games 1988, 78% of all lower extremity injuries reported in the Canadian team occurred in the blind athletes (Burnham et al., 1991) and during the Paralympic Games 2010, injuries from falls were more common in VI Nordic skiers (Webborn et al., 2012). Athanasopoulos et al. (2009) suggested that the high incidence of ankle injuries in VI athletes may be related to poor proprioception, and it has been stated that postural stability is affected by vision (Aydog et al., 2006). Orthopedic deformities in the foot and knee region are sometimes present in individuals with CP (Horstmann et al., 2009). Patatoukas et al. (2011) showed that CP athletes had a higher percentage of soft tissue injuries compared with other athletes, and the authors suggested that limited range of motion, spasticity, and discoordination might cause additional stress to muscles, joints, and tendons. Athanasopoulos et al. (2009) proposed that the greater number of lower extremity injuries in athletes with CP may be related to increased tensile forces in the lower extremity as a result of spasticity and deformities. Amputee athletes appeared to have a high prevalence of injury and pain (Nyland et al., 2000; Bernardi et al., 2003; Athanasopoulos et al., 2009), and it has been suggested that the high number of injuries might depend on altered biomechanics in the lower extremity (Bernardi et al., 2003). Athletes with a unilateral amputation may also suffer from injuries in the intact lower limb due to asymmetrically higher forces during running (Nyland et al., 2000). In wheelchair athletes low bone mineral density could be considered as a possible intrinsic risk factor for injury. Osteoporosis occurs in almost every person with SCI, which results in an increase in the incidence of lower extremity fractures (Jiang et al., 2006). McCormack et al. (1991) reported seven fractures among 90 wheelchair athletes. Patatoukas et al. (2011) showed that SCI athletes had a significantly higher prevalence of fractures compared with other athletes. Four fractures were reported in ice sledge hockey players during the Winter Paralympic Games 2002. A regulation change on protective equipment and sledge height was implemented thereafter, and only one fracture was reported in 2010 (Webborn et al., 2012), which should be considered a successful prevention work. Moreover, wheelchair athletes had a high frequency of upper extremity injuries (Burnham et al., 1991; Derman et al., 2013), and these athletes often rely on their upper extremities both in their daily life as well as in sports, which could cause a high stress on their tissues. The disability might also be associated with a seated posture, a smaller upper extremity musculature, denervated musculature, flaccidity, muscle spasms, and spasticity (Asayama

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et al., 1985; McCormack et al., 1991), which all should be considered as intrinsic risk factors. Burnham et al. (1991) suggested that weakness of the external rotators and shoulder adductor muscles can contribute to shoulder impingement in these athletes. The problem is often exacerbated because the sitting posture in a wheelchair is characterized by internal rotation of humerus and scapular protraction. Upper extremity injuries were also the most frequently reported during the Summer Paralympic Games 2012, and it has been suggested that future research should put emphasis on understanding injury factors and prevention strategies of these specific anatomical regions (Derman et al., 2013). Also, the authors of the injury surveillance from the Olympic Games 2012 recommend further development of preventative measures tailored for each specific sport (Engebretsen et al., 2013). Very few of the studies reviewed have discussed intrinsic or extrinsic risk factors. Ferrara and Davis (1990) recommended physical screening of flexibility, strength, and cardiovascular function of all athletes to determine any deficiencies that might predispose the athlete for injury. Also, Reynolds et al. (1994) recommended pre-event screening of injuries to provide better medical support. Discussion It is apparent that existing studies within the area have poor injury definitions. The methodologies, rate denominators, and populations have varied widely between the reviewed studies. Few studies are sports and disability specific, and some studies use cross-disability design, which makes it difficult to determine sports and disability specific risk factors. Many studies use the term wheelchair athlete. However, there are a variety of disabilities and classification systems of wheelchair athletes, and each disability group may have different movement patterns and performance levels (Patatoukas et al., 2011). Magno e Silva et al. (2013b) stated that to be able to recognize different risk factors within disability sports, it is important to report etiology and injury prevalence by disability and sports. Few studies report accurate information on characteristics of the subjects, data collection, and surveys. Only three out of 25 studies included the age range of the athletes studied, and this is a limitation that is suggested to be addressed in future studies. Only one of the studies reported that the injury survey was validated (Ferrara et al., 1992a). The sample sizes have sometimes been small, and some studies did not report the specific nature of injury (Table 1). Also, the classification systems of injury have varied between studies. For example, Ferrara and Davis (1990) classified a minor injury as an injury that caused time loss from training of 7 days or less, whereas one study include a blister as an injury (McCormack et al., 1991). Few studies report incidence, exposure, and time loss of training due to an injury. In injury epidemiology of

Injuries in athletes with disabilities able-bodied athletes, time loss of training is a commonly used parameter to describe severity of injury (Kjaer et al., 2005). Variations in the definitions and methodologies used for studies of injuries in Paralympic sports today cause inconsistencies in reported data, and comparisons of results are difficult. Present studies just provide information from short-term surveillance during competitions, and most of the definitions used are not adopted for overuse syndromes that develop over time. In several sports for able-bodied athletes, consensus statements on definitions and data collection procedures of sports injuries are available, and it is clear that similar consensus is needed within Paralympic sports. In the future, it is recommended that larger and better designed studies concerning injury epidemiology are conducted within the area of Paralympic medicine. Standardization of injury definition, nature of injury, and surveys are recommended. Sports and disability specific studies are preferred, and risk factors should be evaluated. Very few studies present information regarding long-term consequences of an injury in disability sports. Therefore, longitudinal studies following disabled athletes over time are recommended, which would also allow researchers to estimate injury IRs based on athlete exposures. Furthermore, it is important to examine the consequences of an injury upon quality of life. The injury surveillances conducted by the IPC at the Paralympic Games 2002, 2010, and 2012 have been very successful and represent a huge step forward in understanding injuries in Paralympic athletes during competition. During the Summer Paralympics Games 2012, the injury incidence proportion was 17.8 injuries/100 athletes (Willick et al., 2013) compared with the injury rate of 12.9 injuries/100 athletes during the Summer Olympic Games (Engebretsen et al., 2013). These results suggest that the injury panoramas today are almost equal in athletes with disabilities compared with able-bodied athletes. However, there are still very few studies of injury incidence in disabled athletes during their normal training season. Further research in this area could include the development of an international scientific injury surveillance system for athletes with disabilities, along the lines with the system used during the Paralympic Games in London 2012. With continuous data over several seasons, it would be possible to observe the development of specific trends over time and to monitor and assess the type of

training, load, and exposure. This information could possibly help coaches, trainers, physicians, and therapists to understand and reduce risk factors of injuries and to better plan training and competition phases. An enhanced knowledge of injury epidemiology could also help researchers to better understand injury mechanisms and thereby develop and implement effective injury prevention programs. It is therefore recommended that future studies also examine the effects of prevention strategies in athletes with disabilities. And, most importantly, knowledge in this field could also help athletes to increase their sports performance and improve their quality of life.

Perspectives The Paralympic Games is currently the world’s second largest sporting event with regard to the number of participants. Paralympic athletes have become elite in their sport, and a consequence of this is increased fitness levels and training time (Vanlandewijck & Thompson, 2011). It is well known that participation in sports, especially at elite levels, places the athlete at risk for musculoskeletal injury (Ljungqvist et al., 2009). Based on the information in this review, it is clear that the few existing studies of injuries in Paralympic sports show that overall rates seem to be high and comparable with rates in able-bodied athletes. Epidemiological data regarding the nature of injuries, and sports and disability risk factors are very limited. Furthermore, few studies have assessed injury prevention strategies. It is also apparent that some of the existing studies have poor injury definitions and methodologies. In the future, consensus statements on sports injury definitions and data collection procedures of sports injuries are recommended within Paralympic sports. Key words: Disability, epidemiology, paralympic, sports, wounds and injuries.

Acknowledgements Kristina Fagher, MSc, RPT, is a contracted physiotherapist for the Swedish Paralympic Women’s Goalball Team. Jan Lexell, MD, PhD, is Chief Medical Officer in The Swedish Sports Organization for the Disabled and The Swedish Paralympic Committee.

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Sports-related injuries in athletes with disabilities.

The number of athletes with disabilities participating in organized sports and the popularity of the Paralympic Games is steadily increasing around th...
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