Lesão e Pessoa com deficiência no Atletismo

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Lesão e Pessoa com deficiência no Atletismo

  1. 1. . . . Published ahead of Print D Sports Injuries in Paralympic Track and Field Athletes with Visual Impairment TE Marilia Passos Magno e Silva1, Ciro Winckler2, Anselmo Athayde Costa e Silva1, James Bilzon3, and Edison Duarte1 1 Department for Adapted Physical Education, University of Campinas, Brazil 2 Department for Movement Science, Federal University of Sao Paulo, Brazil 3 Department for Health, University of Bath, United Kingdom EP C Accepted for Publication: 19 November 2012 CAMedicine & Science in Sports & Exercise ® Published ahead of Print contains articles in uneditedmanuscript form that have been peer reviewed and accepted for publication. This manuscript will undergocopyediting, page composition, and review of the resulting proof before it is published in its final form.Please note that during the production process errors may be discovered that could affect the content. Copyright © 2012 American College of Sports Medicine
  2. 2. Medicine & Science in Sports & Exercise, Publish Ahead of Print DOI: 10.1249/MSS.0b013e31827f06f3 Sports Injuries in Paralympic Track and Field Athletes with Visual Impairment Marilia Passos Magno e Silva1 Ciro Winckler2 Anselmo Athayde Costa e Silva1 D James Bilzon3 Edison Duarte1 1 2 3 TE Department for Adapted Physical Education, University of Campinas, Brazil Department for Movement Science, Federal University of Sao Paulo, Brazil Department for Health, University of Bath, United Kingdom EP Corresponding author: Dr James Bilzon C Address: Department for Health, University of Bath, Bath BA2 7AY UK. Telephone: +44 (0)1225 383174C Fax number: +44 (0)1225 383833 E-mail: j.bilzon@bath.ac.ukA Running title: Injuries in Visually Impaired Athletes Disclosure of funding: None of the authors have professional relationships with companies or manufacturers who will benefit from the results of the present study. All authors declare no conflict of interest.Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
  3. 3. Abstract Purpose: The aim of this study was to determine the epidemiology, nature and pattern of sports injuries in Brazilian Paralympic track and field athletes with visual impairment and assess differences between visual classes and sex. Methods: Forty visually impaired elite Paralympic athletes participated in this study (28 males and 12 females). All athletes competed in International Paralympic competitions between 2004 and 2008. According to the D visual classification, 14 athletes were T/F11, 15 T/F12 and 11 were T/F13. A standardised report form was used to collect injury data during five competitions. Results: Thirty-one TE athletes reported 77 sports injuries, with a prevalence of 78%, a clinical incidence of 1.93 injuries per athlete, an incidence rate of 0.39 injuries per athlete per competition. Overuse injuries accounted for 82% and traumatic injuries 18% (p<0.05). Small variations in the EP prevalence and clinical incidence of injury between sexes and visual classes were observed, but these were not statistically different (p>0.05). The highest distribution of injury was in the lower limbs (87%), followed by spine (12%) and upper limbs (1%). The body regions most affected were the thighs (33.8%), lower legs (16.9%) and knees (9.1%). The most C frequent diagnoses were spasms (26%), tendinopathies (23.4%), and strains (13%).C Conclusion: Elite visually impaired track and field Paralympic athletes present a pattern of overuse injuries predominantly affecting the lower limbs, particularly the thighs, lower legsA and knees. These injuries are associated with tendinopathies, muscle spasms and strains. There were no apparent differences in injury characteristics between visual classes or sex. Key words: athletics; disability sport; injury epidemiology; ParalympicsCopyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
  4. 4. Introduction Paragraph Number 1 Athletics was one of only eight sports included in the first Paralympic Games, held in Rome, in 1960. In this first Paralympiad, only throwing and pentathlon events were performed. In the modern Paralympic Games, track and field athletics is the sport with the largest number of participating athletes, competing in eight track events (100m, 200m, 400m, 800m, 1.500m, 5.000m, 10.000m and marathon), six field events (long jump, high D jump, triple jump, javelin, discus and shot put) and one combined event (pentathlon). They compete in male and female categories, and are classified in one of the 26 sport classes, TE according to their disability type and motor function (motor, physical, visual and intellectual). Athletes who participate in track events use the letter T before the class number, to indicate the event type, whilst those participating in field events use the letter F (18). This short EP introduction serves to highlight the complexity and variety of Paralympic athletic events, which is also reflected in the development and understanding of research in the discipline. Paragraph Number 2 To compete, visually impaired athletes must be submitted to a Visual C Classification, where an ophthalmologist evaluates acuity and visual field. Athletes can beC categorized in one of three levels: B1 are considered blind athletes (from no light perception in either eye, up to light perception, but unable to recognize the shape of a hand at anyA distance or direction); B2 are considered to have severely impaired vision (from ability to recognize the shape of a hand up to a visual acuity of 20/600 or a visual field of less than 5 o in the best eye with the best practical eye correction); B3 are considered to have moderate to poor vision (from visual acuity above 20/600 to 20/200 or a visual field of less than 20 o and more than 5o in the best eye with the best correction) (22). In track and field athletics, these classifications are given sport-specific nomenclature, respectively as follows: T/F11, T/F12Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
  5. 5. and T/F13. The Track and Field Paralympic Rules determine that acoustic assistance and a guide are permitted for the classes T/F11 and T/F12. Athletes T/F11 should wear opaque glasses to match the capacity of light perception between the competitors. The T/F13 athletes follow the same rules as the regular athletics (18). Paragraph Number 3 The practice of competitive sport predisposes all individuals to sports injuries, irrespective of disability. It would seem logical to hypothesise that certain D disabilities, such as visual impairment, may predispose athletes to a greater incidence of sports injuries when compared to able body athletes. Epidemiological studies related to sports TE injuries are therefore important: to allow participants or prospective participants to make informed choices about participating, based on the risk of injury; to provide information for medical and health care professionals to ensure care in disability sport; to direct researchers, EP practitioners and administrators to develop preventive strategies and create a safe environment for participation in training and competition (16). Paragraph Number 4 Relatively few studies have been conducted into the epidemiology of C sports injuries in athletes with disabilities (7,9,10,11,12,13,19,24,27,28,29,31,33). Most ofC these studies have adopted a cross-disability or multi-sport research design creating problems in interpreting results, since different disabilities may manifest in different injury patterns andA frequencies, making it difficult to interpret and apply findings to specific groups, as well as to compare results between studies, with the ultimate aim of reducing injury incidence (13). Sports injuries may also be related to risk factors, which are usually classified as being extrinsic (e.g. sport, rules, climate, surface, equipment) or intrinsic (e.g. body composition, age, sex, flexibility, strength, balance, proprioception), with many intrinsic risk factors considered modifiable (3). With regard to Paralympic sport, the disability must be consideredCopyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
  6. 6. as an intrinsic risk factor that cannot be modified (24). Paragraph Number 5 According to previous studies, visually impaired athletes sustain more overuse injuries, in the lower limbs, particularly the knee, leg, ankle and feet, and the most frequent diagnoses are tendinopathy, strain and contusion (7,10,27). There are also reports of a relatively high prevalence of injuries to the lumbar and cervicothoracic spine of these athletes (27). During the Paralympic Games in Barcelona 1992, of the 60 multi-disability athletes in the British Paralympic track and field team, 80% were affected by sports injuries D (29). Another study, with the Brazilian Paralympic athletics team, revealed that the lower limbs (64.9%) were most affected by injuries, followed by spine (19.3%) and upper limbs TE (15.8%), and the most frequent diagnoses were tendinitis, strain and spine pain (33). Paragraph Number 6 Unfortunately, to date, there are few published studies that have EP investigated and reported injuries by sport and disability type, and those do not reveal the true pattern and nature of injuries in elite visually impaired track and field athletes. The aim of this study was therefore to determine the pattern of sports injuries in visually impaired track and field athletes from the Brazilian Paralympic team, and assess differences between visual C classes and sexes.CA Methods Paragraph Number 7 This was a descriptive, observational, analytic epidemiological study regarding sports injuries in visually impaired elite Brazilian track and field athletes from the Paralympic team. Ethical approval was obtained from the University of Campinas Ethical Committee. The Brazilian Paralympic Committee (CPB) and the Brazilian Confederation of Sport for Blind Athletes (CBDC) were in agreement with this study.Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
  7. 7. Participants Paragraph Number 8 Forty elite athletes with visual impairment gave informed consent to participate in this study, 12 were female and 28 were male. With regard to their visual class, 14 athletes were T/F11, 15 T/F12 and 11 T/F13. Table 1 presents athletes participation by event. All athletes were representing the Brazilian athletic team in international competitions, between the years of 2004 and 2008. Their participation varied depending on squad selection D for each event. Sports injury data were collected using a standardised report form, which was used consistently by practitioners during the following competitions: Paralympic Games 2004 TE (Greece), International Blind Sports Federation Pan-American Games 2005 (Brazil), International Blind Sports Federation World championship 2007 (Brazil), Para Pan-American Games 2007 (Brazil), Paralympic Games 2008 (China). EP Definition of Terms Paragraph Number 9 A reportable injury was defined as any injury that caused an athlete to C stop, limit or modify participation for one day or more (9,11). To standardize the location ofC injury the body was divided into the following segments and regions: Head (head, face); upper limbs (scapular, shoulder, arm, elbow, fore-arm, wrist, hand, fingers); lower limbsA (pelvis, hip, thigh, knee, lower leg, ankle, feet) and spine (cervical, thoracic, lumbar). The mechanism of injury was determined as traumatic (resulting from a specific, identifiable event) or overuse (caused by repeated micro trauma without a single, identifiable event responsible for the injury) (14). Paragraph Number 10 Three epidemiological measures (prevalence, clinical incidence, andCopyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
  8. 8. incidence rate) were evaluated in this study. Prevalence is defined as the proportion of athletes who have an existing injury at any given point in time; it is calculated by dividing the number of injured athletes by the number of athletes exposed at the specified time (15,21). clinical incidence is a hybrid measure of incidence that represents the average number of injuries per athlete; it is accessed dividing the number of injuries by the number of athletes at risk (21). Incidence rate is the number of injuries divided by the total person-time at risk (athlete-exposures) (21). In this study the athlete exposure was represented by competition D and year. Injury Report Form TE Paragraph Number 11 A standardised injury report form, used routinely by the CPB and EP CBDC, required documentation of the following information: athlete name, age, sex, visual classification, sport, event, injured body part, mechanism and diagnosis of injury. During the competitions, the multidisciplinary Brazilian medical team consisted of doctors, physiotherapists and nurses. The orthopaedic doctors determined the precise diagnosis of C each sports-related injury. Sports injuries that occurred outside the period of competitionC were not recorded. Where athletes suffered a recurrent injury, the injury was counted only once.A Statistical Analysis Paragraph Number 12 Data were collated using Microsoft Excel 2007® and analysed using the SPSS 14.0®. Descriptive statistics were calculated and used to determine the total and relative frequency of injuries. The Shapiro-Wilk test was used to determine the normality ofCopyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
  9. 9. data distribution. Where the normality of data distribution could be assumed, a one-way analysis of variance (ANOVA) test for independent groups was used to assess differences between visual classes and track and field events, and a t-test was used to compare between sexes. Alternatively, the Kruskal-Wallis test was used to assess differences between sexes and visual classes. The acceptance level of significance was set at p< 0.05. D Results Paragraph Number 13 Forty athletes participated in this study and 31 suffered a total of 77 TE sports injuries (Table 1), which correspond to a Prevalence of 78%, a clinical incidence of 1.93 injuries per participating athlete (Table 1), and an average Incidence Rate of 0.39 injuries per athlete per competition. EP Paragraph Number 14 Female athletes presented a slightly higher prevalence and clinical incidence when compared to male athletes (Table 1), but this was not statistically significant (p>0.05). With regard to visual class, T/F11 athletes presented a slightly higher prevalence of C sports injuries, followed by T/F12 and T/F13 athletes. However, T/F12 athletes showedC slightly higher clinical incidence, followed by T/F11 and T/F13 (Table 1). There were no statistically significant differences observed between classifications or groups in theseA epidemiological data (p>0.05). When comparing the epidemiological data between event types such as track (sprint, medium and long distance) and field (throws and jumps), no statistically significant differences were observed. Paragraph Number 15 With respect to injury mechanisms (Figure 1), overuse injuries were the most prevalent (82%) and traumatic injuries constituted the remaining smaller proportionCopyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
  10. 10. (p<0.05). Paragraph Number 16 Figure 2 represents the distribution of sport injuries by body segment, where the lower limbs appeared to be most affected. Paragraph Number 17 The frequency of injuries by body region (Figure 3) revealed that the thighs were most affected. D Paragraph Number 18 The frequency of sport injuries varied by diagnosis (Figure 4), with the greatest frequencies reported as tendinopathy and spasm. Discussion TE EP Paragraph Number 19 The results of this study demonstrate that the overall clinical incidence was 1.93 injuries per injured Paralympic athlete during the period of observation, indicating that many athletes sustained multiple injuries (21). Paralympic track and field is considered a low risk sport when compared to other Paralympic sports modalities (12). In C terms of sports injury prevalence, we demonstrated an overall value of 78%, varying fromC 82% to 36% across the 5 competitions observed (Table 1). A previous study in track and field athletes without disability observed an injury prevalence of 42.8% (17).A Paragraph Number 20 When comparing sports injuries by sex, female athletes presented a slightly higher prevalence (92% vs. 71%) and clinical incidence (2.3 vs. 1.8 injuries per athlete) of injury (Table 1) compared to males. This trend suggests that a higher proportion of female athletes were injured and those that were, sustained more injuries per athlete compared to males. Whilst these observations were not significantly different, this may be aCopyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
  11. 11. function of the relatively small sample size stemming from a single nation team. There seems to be very little difference in the pattern of injuries between men and women when comparing the same sports among able-bodied athletes (30). A review article suggests that the risk of sports injuries is lower in female than in male athletes without disability (20). Clearly, further studies should be encouraged to evaluate the risk of injury by sex in Paralympic sport. In order to address this question fully, greater statistical power is required, which may ultimately require the collection and collation of data, using common injury D reporting methods across multiple nations. TE Paragraph Number 21 With regard to visual class, T/F11 athletes presented a higher Prevalence of injury, but B2 athletes a higher clinical incidence; this means that a larger percentage of T/F11 athletes was injured, but B2 athletes sustained more injuries, but no EP statistical significance was revealed. In addition, another study with 131 visually impaired athletes affirms that the prevalence of injury is greatest among athletes with the greatest visual impairment (24). This can be related to the fact that postural stability is affected by vision (2), and proprioception in blind individuals tends to be worse than in those with partial C vision resulting in abnormal gait and biomechanics, that can lead to injuries (34). TheseC findings suggest that the implementation of proprioception training, as a preventive measure, may be useful to reduce the prevalence and clinical incidence of sports injuries in athletesA with visual impairment. Paragraph Number 22 Overuse injuries were most frequently observed in this population. This mechanism of injury is not atypical in sport modalities characterized by repetitive weight-bearing movements, particularly where there is relatively little or no contact between the competitors (5). Able-bodied track and field athletes also have the predominance ofCopyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
  12. 12. overuse injuries (4). During training and competitions in running events for able-bodied athletes, the musculoskeletal system is exposed to long periods of repetitive stress, and it is estimated that the feet strike the floor 1000 to 1500 times per mile (26) with forces two to three times the body mass (32). Paragraph Number 23 With respect to the body segments, the lower limbs were most affected by sports injuries. Again, this is possibly because this sport has a large number of D events that cause an overload in this body segment. In general, visually impaired athletes sustain more injuries in the lower limbs (7,9,27). Non-visually impaired track and field TE athletes also present a high frequency of sport injuries in the lower limbs, suggesting that the type and frequency of injuries are related more to the sport than the disability per se (1,35). EP Paragraph Number 24 Athletes with disabilities are often referred with soft tissue injuries (tendons, ligaments, muscle, joint capsule) (13,27,28). The same distribution pattern was found in this study, where tendinopathies, spasms and strains were the most common injuries. In able-bodied athletes muscle strains, inflammatory conditions and joint sprains are also C common types of injury (17,35).C Paragraph Number 25 The thighs were particularly affected by spasms and strains. ThisA body part incorporates biarticular muscles (e.g. hamstring and rectus femoral), which are predisposed to injuries, often during explosive movements such as accelerations out of the starting blocks, or deceleration movements, particularly in sprinters (4,23). Tendinopathies predominantly affected the thighs, knees and lower legs, probably because these structures appear extremely prone to injuries associated with overload and repetitive movements, as previously discussed. In addition, athletes with visual impairment may expend more energyCopyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
  13. 13. than other athletes when performing athletic events and are more likely to fatigue quickly (25). This may, in part, predispose these athletes to a higher incidence of overuse injuries in the lower extremity (10). According to previous study track and field athletes without disability sustain injuries mainly in the knee and lower legs (17). Paragraph Number 26 Injuries to the spine were responsible for 12% of all injuries, particularly in the lumbar spine (9.1%). A previous study has demonstrated a relationship D between visual impairment and changes in posture, where visual impairment predisposes individuals to pathologies in the spine, such as scoliosis (8). In addition, running causes a TE compressive force in the lumbar spine that increases with the velocity and during the impact phase (6). A good physical assessment to identify muscle imbalances related to posture, and the implementation of core stability training can work as a preventive measure to avoid the EP development of injury in this group. The upper limbs exhibit an injury prevalence of 1.3%, represented by one athlete that competed in throwing events (discus, shot put, and javelin) and sustained a finger injury. In able-bodied athletes upper limb injuries are also related to throwing events (35). CC Paragraph Number 27 Analyzing the patterns of the mechanism and distribution of sports injuries in this study, and comparing them with previous studies with non-visually impairedA athletes, it seems logical to summarize that the prevalence of overuse injuries in the lower limbs is inherently related to the sport, particularly the repetitive movements associated with weight-bearing, rather than the disability itself. This study demonstrated that in visually impaired track and field athletes, the lower limbs were most affected by tendinopathies, spasms and strains, particularly in the thighs, legs and knees. Variables such as visual class (T/F11, T/F12, T/F13) and sex did not reveal any significant statistical differences in clinicalCopyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
  14. 14. incidence or Prevalence, but trends suggest they are worthy of further investigation. Further studies that access the training load, type of event, overall athlete exposure in competition and training, and relate these data to the sport injury, are important to understand the relation between the intrinsic and extrinsic factors of sports injuries. This requires a strategic approach, utilizing electronic sources to optimize the capture and analysis of data. D Acknowledgments TE The authors thank all the Brazilian Paralympic Athletes, the Brazilian Confederation Sports for Blind Athletes (CBDC), the Brazilian Paralympic Committee (CPB) and the Coordination for the Improvement of Higher Level -or Education- Personnel (Coordenação de EP Aperfeiçoamento de Pessoal de Nível Superior-CAPES). The authors do not have any financial disclosures to report. The present study was unfunded. The results of the present study do not constitute endorsement by the American College of Sports Medicine. CCACopyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
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  20. 20. Figure Legends Figure 1 – Mechanism of sport injury in track and field Paralympic competitions Figure 2 – Distribution of sport injury by body segment in track and field Paralympic competitions D Figure 3 – Distribution of sport injury by body part in track and field Paralympic competitions TE Figure 4 – Distribution of sport injury by diagnosis in track and field Paralympic EP competitions CCACopyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
  21. 21. Figure 1. D TE EP CCACopyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
  22. 22. Figure 2. D TE EP CCACopyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
  23. 23. Figure 3. D TE EP CCACopyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
  24. 24. Figure 4. D TE EP CCACopyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
  25. 25. Table 1: number of participants athletes, injured athletes, sports injuries, prevalence and clinical incidence according visual class, event type and sex. Visual Class Event type Sex Total Competitions T/F11 T/F12 T/F13 Track Field Female Male Participants Paralympic Games 2004 4 5 2 11 - 5 6 11 IBSA Para Pan-American Games 2005 8 12 8 25 3 7 21 28 IBSA World Championship 2007 9 12 7 25 3 8 20 28 Para Pan-American Games 2007 7 8 4 19 - 6 13 19 D Paralympic Games 2008 8 10 4 22 - 8 14 22 Total 14 15 11 35 5 12 28 40 Injured athletes TE Paralympic Games 2004 3 5 1 8 - 4 5 9 IBSA Para Pan-American Games 2005 3 7 3 12 1 4 9 13 IBSA World Championship 2007 6 7 4 14 3 6 11 17 Para Pan-American Games 2007 2 4 3 9 - 4 5 9 Paralympic Games 2008 2 6 1 8 - 3 5 8 Total 12 12 7 27 3 11 20 31 EP Number of sports injuries Paralympic Games 2004 3 7 1 11 - 5 6 11 IBSA Para Pan-American Games 2005 5 8 3 15 1 4 12 16 IBSA World Championship 2007 7 14 7 22 6 8 20 28 Para Pan-American Games 2007 3 4 4 11 - 6 5 11 Paralympic Games 2008 3 6 2 11 - 3 8 11 C Total 21 39 17 70 7 27 50 77 Prevalence Paralympic Games 2004 75% 100% 50% 73% - 80% 83% 82%C IBSA Para Pan-American Games 2005 38% 58% 38% 48% 33% 57% 43% 46% IBSA World Championship 2007 67% 58% 57% 56% 100% 75% 55% 61% Para Pan-American Games 2007 29% 50% 75% 47% - 67% 38% 47% Paralympic Games 2008 25% 60% 25% 36% - 38% 36% 36%A Total 86% 80% 64% 77% 60% 92% 71% 78% Clinical incidence Paralympic Games 2004 0.8 1.4 0.5 1.00 - 1.0 1.0 1.0 IBSA Para Pan-American Games 2005 0.6 0.7 0.4 0.60 0.33 0.6 0.6 0.6 IBSA World Championship 2007 0.8 1.2 1.0 0.88 2.00 1.0 1.0 1.0 Para Pan-American Games 2007 0.4 0.5 1.0 0.58 - 1.0 0.4 0.6 Paralympic Games 2008 0.4 0.6 0.5 0.50 - 0.4 0.6 0.5 Total 1.5 2.6 1.5 2.00 1.40 2.3 1.8 1.9Copyright © 2012 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

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