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| Feature | No.61 May 2011 |

Coaching athletes with disabilities: Challenges and Recommendations
Nagoor Meera Abdullah, Kwame Ampofo-Boateng, Rozita Abdul Latif & Hisyam Che Mat
Abstract
This article briefly discusses athletes with disabilities and how their condition can be matched with suitable activities to allow them to participate in physical activity and sports. The article also aims at assisting coaches who conduct training for people with disability to understand their condition first, and then devise programmes that are appropriate for their condition. Furthermore, it highlights the barriers and conditions that affect athletes with disability`s participation in sports, especially those related to the health, safety and medical considerations that coaches should understand and manage carefully. The article also offers recommendations on how coaches should train athletes with disability.
Introduction
Sport for the persons with disabilities, just like their able bodied peers, provides many benefits, including: increased strength and endurance; improvements in performance; restoration of mental activity; increased self-confidence, and overall improvement in quality of life. Moreover, sports play a major role in social, medical, educational and vocational aspects of comprehensive rehabilitation programmes for people with disability. For these reasons, the first competitive sports for the physically disabled were introduced by Sir Ludwig Guttmann at Stoke Mandeville Hospital in 1948. These were called the Stoke Mandeville Games (SMG), and continue today as the International Stoke Mandeville Games (Skaggs & Hooper, 1996).
Although able-bodied and persons with disabilities focus on their quality of life and wellbeing (Van der Woude, Veeger & Rozendal 1989), those with disability generally are less likely to have opportunities to be active, making health concerns due to inactivity greater than for the able-bodied (Block, 1995; Colak, Bamac, Aydin & Ozbek, 2004; Longmuir & Bar-Or, 2000; Messent, Cooke & Long, 1999; Pitetti, Climstein & Barret, 1992). For example, persons who are visually-impaired use more energy during activities of daily living (Buell, 1982) and tend to have lower levels of physical activity and health-related fitness than those who are sighted (Horvat, Ray, Ramsey, Miszko, Keeney & Blasch, 2003; Lieberman, Byrne, Mattern, Fernandez-Vivo & Robinson, 2006; Sit, Lindner & Sherill, 2002; Williams, 1990). Furthermore, impairments affect muscle strength and motor control performance for those with motor impairments and these can limit participation in sports.
With the special needs of persons with disabilities in mind, coaches should design training programmes to deal appropriately with these needs. In fact, coaching athletes with disabilities is not a difficult task if a coach is able to accept each participant as an individual and deal with their specific needs and conditions. As a coach, it is important to be aware of each person`s disability and the level at which these athletes are capable of functioning. Remember that even people with the same physical condition may choose different activities and develop the skills associated with those activities, albeit to different levels of performance (Note: throughout this article, the term condition(s) is used synonymously with disability (disabilities)). Coaches should also understand the definitions of different types of disability. For example, coaches should understand the differences between athletes with Cerebral Palsy (CP), amputations and spinal cord injury (SCI). They should also be aware that mental disabilities can be grouped into various conditions such as Down syndrome, slow learner, autism, dyslexia and mental retardation. There are also other categories of disabilities, including athletes who are visually-impaired and hearing-impaired. Physical disabilities may also affect mobility, balance, agility, strength, endurance, cardiovascular or a combination of these. The foregoing lists different types of disabilities that might influence sports participation and performance which coaches should consider as they train athletes with disabilities.
Important factors to consider when training athletes with disabilities
Below are some important aspects that coaches need to consider in developing their training programmes for athletes with disabilities.

- Keep a good balance between mind, technique and the body of athletes with disabilities in training programmes.
- Accept each athlete`s disabilities/physical conditions as unique and design appropriate training programmes for them.
- Have adequate knowledge of the rules and laws of sport and how they might affect athletes with disabilities.
- Develop an awareness of the equipment that athletes with disabilities use including gloves, rams and wheelchairs and make sure they are suitable for the particular sports.
- Compared to coaches of able-bodied athletes, coaches of athletes with physical disabilities require greater flexibility and lateral thinking in order to attain the best possible movement patterns for their athletes.
- Coaches of athletes with physical disabilities have to address the added dimension of analyzing the movements of an asymmetric body with a restricted range of movement (ROM).

While the above are general advice for coaches for training athletes with disabilities, we now discuss athletes with specific disabilities and their particular needs that coaches must incorporate into training. These athletes with specific disabilities are visually-impaired athletes, athletes with amputations, athletes with neurological conditions, athletes with cognitive disabilities and athletes who are deaf.
Visually-impaired athletes
Most of the studies related to visually-impaired athletes suggest that athletes who are visually-impaired are prone to inactivity throughout their life span, and this is confirmed by studies focusing on children with visual impairments that indicate that they engage in less physical activity than persons with other disabilities (Lieberman & McHugh, 2001; Rimmer, Braddock & Fujiura, 1993). Moreover, they also demonstrate delayed motor development, such as poor balance and inefficient gait, which may be due to their sedentary behaviours during the developmental years (Bouchard & Tetrault, 2000; Higgs, 1990). Concomitantly, vision loss may affect skill acquisition, such as running, throwing and jumping techniques in several ways (Bouchard & Tetrault, 2000; Higgs, 1990). It is also more difficult to learn physical skills through verbal instruction than demonstration, and this limits the opportunities available to visually-impaired athletes to learn new skills (Bouchard & Tetrault, 2000).
Many athletes who are totally or partially blind are unable to use vision to determine the proper direction while running, throwing or adjusting the direction of the throws and in athletics and swimming events, visually-impaired athletes need to know when they are approaching the end of their race. The use of verbal descriptions by a coach during demonstrations is ideal, while using hand-body manipulation and brailing techniques during warm-up and skill sessions can make it easier for coaches to conduct these training sessions. Coaches should understand that sports participation by the visually-impaired athletes usually requires the use of a guide or partner. Sports like lawn bowl require assistance from a director for athletes to know and maintain the direction of their throws, while runners in athletics require a guide runner and tether (or rope) to guide the athlete to the finish line.
For field events, especially jumping events, the coach has to train a visually-impaired athlete to use step counts to estimate the length of the runaway. In swimming, it is suggested that a coach should instruct assistants to use the device called a tapper, in order to tap the back of visually-impaired athletes in swimming events, to make them aware that they are approaching at the end of the pool. In cycling events, a front rider, together with the visually-impaired athlete sitting at the back, use a tandem bicycle.
As previously mentioned, methods such as hand-body manipulation technique and brailing technique would also be beneficial in assisting a visually-impaired athlete learn new skills. For example, with regard to hand-body manipulation, a coach could manipulate the athlete`s limbs in such a way as to allow the execution of a skill or movement, while brailing technique could help athletes use their kinesthetic-tactile senses to feel the movement or skill that their coach is executing.
Athletes with amputations
Amputations refer to a condition in which part or all of one or more extremities are missing. An athlete with arm or leg amputations might experience problems with balance and speed while executing running, jumping and throwing motions. Therefore, coaches must be creative when applying principles of biomechanics for these athletes. One example is when coaching an athlete or sprinter with a single above elbow (AE) amputation, performance in balance and sprinting ability decreases because without upper limb(s), the body cannot propel efficiently to generate force. Using a hand prosthesis may be a good solution but wearing a prosthesis requires good skin care, including skin checks, to avoid skin stress due to abnormal shearing forces. The same applies to leg prostheses. Using leg prostheses can increase speed of the athlete as it is biomechanically efficient.
In jumping events, athletes tend to not use leg prostheses because they are uncomfortable and the prosthesis may cause problems during jumping. It is also not advantageous to use prostheses in an event such as high jump, since the force from the amputated leg will be transferred to the jumping leg during the take-off phase. In running events, using the J-shaped prosthesis might give an advantage to the runner, especially those with below knee (BK) amputations. Oscar Pistorius (a South African runner who has double below-knee amputations and runs using carbon-fiber blades) wished to run at the Beijing Olympics in 2008 but was not allowed, due to, what were considered by some as his additional mechanical aids. He is, however, still known as “the fastest man on no legs” and has run the fastest 400 meters with a time of 46.90 seconds, and has created a phenomenon by proving that running technique is not always the same as our previous understanding from theories and books. For example, in November 2007, German professor Gert-Peter Brueggemann began testing Oscar Pistorius advantages and his study found that the artificial limb used 25% less energy than able-bodied runners to run at the same speed, and that they led to less vertical motion combined with 30% less mechanical work for lifting the body. These findings were used by the International Association of Athletics Federations (IAAF) to ban Oscar Pistorius from participating in the Olympics. They later reversed this decision, allowing him to compete in the Olympics, but to qualify on merit by achieving the qualifying time of 45.55 seconds in the 400meter. Pistorius did not achieve this qualifying time.
In swimming, using an artificial limb would not be advisable since it would make the swimmer experience difficulty in movement and create more drag force. However, it is vital for an amputee-athlete to use prostheses in badminton, cycling, lawn bowls, table-tennis and even archery. In throwing events, it is necessary for a shot putter or a discus thrower to use prosthetic legs in order to gain ground reaction force.
Of further interest and consideration for coaches is classification of amputation. In medical terms, amputation can be defined as surgical removal of all or part of a limb, an organ, or projecting part or process of the body. In Paralympics sports, there are various categories of disability, and in a specific category, like amputation, there are also classifications that are different to cater for each group in the amputation. In sports classifications, amputations can be defined as at least one limb missing. Missing limbs here refer to a lost functional joint or joints. Example, if a person loses a finger, he or she may still manage to lift objects, but if he or she lost all fingers, then it would be difficult to lift objects.
In sports classification, there are four (4) categories of amputations:

- Below elbow (BE) amputations- an amputation from elbow joint down to the palm.
- Above elbow (AE) amputations – an amputation from elbow joint and up to the shoulder.
- Below knee (BK) amputations – an amputation from knee joint to the foot.
- Above knee (AK) amputations – an amputation from knee joint to the hip joint.

Thus, if a person lost his or her finger or two, then he or she cannot be considered for participation in Paralympics sports.
Type of amputation certainly affects movement. Do you think an athlete who has below knee (BK) amputation will ran faster than one with above knee (AK) amputation? The higher the level of amputation, the more difficult it is for a person to walk, jog or run. Even using a prosthetic makes it difficult to maintain body balance, which can becomes even more difficult for fast movements such as running or sprinting. For example, athletes with above knee (AK) amputations have difficulties when it comes to getting a great push on the backside of the running cycle and to gain a quicker and more powerful knee drive in the swing phase on the front phase of running, since they cannot flex their knee joint. This results in a `chopping` movement. Athletes with below knee (BK) amputations will have more freedom to run, since they can flex their knee joint to gain ground reaction force to run or sprint in a balanced way.
Athletes with neurological conditions
Athletes with disabilities such as Cerebral Palsy (CP), Acquired Brain Injury (ABI), Stroke and Spinal Cord Injury (SCI) have some difficulties coordinating and controlling their movements. This is because the more severe the condition, the more likely that these athletes will also experience limitations in functional range of motion (ROM). The coach`s aim is to help these athletes achieve greater motor control and greater flexibility.
CP describes a group of disorders that affect the development of movement and posture, causing activity limitation, and are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of CP are often accompanied by disturbances of sensation, cognition, communication, perception, and/or behaviour and/or by a seizure disorder (Bax, Goldstein & Rosenbaum, 2005). CP can be classified by motor involvement and its distributions or pattern. The most common patterns are spastic. Coaches should be aware that some components of movement such as balance, coordination and muscle tone of spastic athletes are affected by their condition and appropriate training programmes should be designed for them. It is recommended that if spastic athletes experience problems in balance while in a standing position during stretching, the coach should allow them to perform stretching in a seated position or receive balance assist from others.
Athletes with paraplegia can utilise their upper limbs to do exercise, whether using isokinetic machines, resistance bands or and passive stretching. This is to enhance their fitness level, blood circulation and also prevent blood pooling especially at the lower limbs. Paraplegic athletes should also avoid sitting too long on wheelchair, since it will lead to the development of pressure sores that can be detrimental to their health.
For athletes with disabilities who are involved in the sport of Boccia, integration of strength training into their programme would be vital. Persons with lower-limb disability who have to rely on manually propelled wheelchairs for locomotion, have a limited mobility and range of action compared to able-bodied individuals. It is, therefore, suggested that wheelchair mobility of disabled athletes can be optimised by improving the vehicle mechanics of the wheelchair, adjusting the wheelchair design to be appropriate for the user, as well as improving the individual`s functional capacity (Thibout, Smith & Labanowich, 1996). In this respect, the assessment of cardio respiratory fitness of wheelchair users has emerged as an important area of interest in the field of sports performance evaluation. Using an arm-crank ergometer or modified shuttle run test can be used to assess those athletes with paraplegia and tetraplegia, with neurological conditions or spinal cord damage.
In order to produce aerobic effects, the amount of effort expended by athletes with some disabilities may have to be greater than that required for athletes without disabilities. Hooker and Wells (in Fox, 2000), for example, found that producing training effects for persons with spinal cord injuries requires higher maximal heart rate levels than the general population.
For athletes with SCI, using resistance training such as bands and cords could help them develop a better feel for the desired movement. SCI athletes, who use sport/racing wheelchairs can propel them well, provided that they have upper body strength. Coaches have to make sure that the paraplegic athletes can throw using the rotation of their waist because some higher classes of SCI athletes depend only on their arms and wrists to throw. Some SCI athletes lose their thermoregulation system function due to their high level of spinal injury. The higher and more complete the spinal cord damage (above T6), the greater the strain to the cardiovascular system and temperature regulation system when the body is exposed to heat (Gehlsen, Davis & Bahamonde, 1990). Most people with paraplegia do not sweat below the level of the injury (Higgs, 1990). This condition is known as poikilothermic (Higgs, 1990). The best way to deal with this condition is for the coach to advise the athlete to wrap cold towels behind the neck, which can function as artificial sweat. These athletes should not be exposed for too long in the hot sun and should drink plenty of water and always cool themselves. If training under the hot sun or in a humid environment, the coach should reduce the intensity or bout length of training and encourage the consumption of more fluid to ameliorate the effect of the heat. Another possible option would be to train in an indoor arena.
Those athletes who have high level of injury tend to loss bowel and bladder control (Gehlsen, Davis & Bahamonde, 1990), so hygiene is very important, to make the athletes comfortable during activity. A coach should make sure to provide an extra catheter and urine bag for athletes.
Also of interest to coaches of wheelchair athletes is the very low heart rates these athletes have, even with high intensity of training.
This is because many wheelchair-athletes have Spinal Cord Injury (SCI), which is damage to the spinal cord that results in loss of functions such as mobility or feeling. Immediately after the spinal cord injury, the loss of movement, sensation and reflexes below the level of the spinal cord injury can occur. Sexual dysfunction and loss of bowel and bladder control may also occur, depending on where the spinal cord injury occurred and if the spinal cord was completely severed or partially severed. The sympathetic nervous system generally excites the body by doing things such as increasing both the heart rate and blood pressure. The parasympathetic nervous system generally calms the body down by decreasing both the heart rate and blood pressure. Both sympathetic and parasympathetic systems are affected by spinal cord injury. As a result, spinal cord injury patients represent a very specific population, whose physiological responses differ significantly from those of able bodied persons (Pare, Noreau, & Simard, 1993). Coutts (1988) investigated the heart rate responses of SCI patients during several different wheelchair sport activities to investigate which activities produced the highest heart rates over sustained periods. Coutts found that the average heart rate elicited during a wheelchair basketball game was 148 bpm. This was the highest average heart rate. Other sports elicited lower rates, including volleyball (115), tennis (128) and racquetball (134). Newly spinal cord injured patients usually have a very low fitness level following hospitalisation, which put them at risk of adverse reactions to maximal training, including the risk of vertebral fractures. Coutts also stressed the need for a standardised piece of equipment such as the wheelchair ergometer to accurately predict aerobic power and establish norms for wheelchair-bound athletes. Some of their significant findings were that the maximal heart rate for paraplegic patients was only approximately 5 bpm lower than the predicted maximum. A larger upper body muscle mass allows a higher efficiency of physiological adaptation to wheelchair exercise, while a smaller muscle mass may induce inappropriate adaptations to exercise such as poor muscle blood flow, higher muscle tension and rapid contribution of anaerobic metabolism (Pare et al., 1993). This evidence makes it clear that it is important to monitor athletes with SCI to ensure they have reached their training zone or capacities, as even with strenuous training, their heart rate will not elevate above 120-140 beats per minute (bpm). It is imperative to design appropriate methods to accurately measure their training capacities.
Athletes with cognitive disabilities
Athletes with disabilities such as mental retardation, severe learning disabilities, Down syndrome, autism and dyslexia generally have physical ability to perform running, throwing and jumping motions using the correct technique. Resistance exercise programmes for individuals and also athletes with mental retardation are especially important because they have positive impacts in relation to undertaking normal activities of daily living (Draheim, Williams & McCubbin, 2002; Frey, McCubbin, Hannigan-Downs, Kasser & Skaggs, 1999). However, coaches will need to give extra attention to principles of motor learning when introducing a new skill, because these athletes tend to forget whatever skills they have recently learned (Messent, Cooke & Long, 1999). A coach should use simple, one-part or two-part direction to introduce new skills gradually and review progress frequently. Especially in running events, to describe using the right or left leg may sometimes not be easily understood by the athletes, and this makes demonstration extremely important in describing and explaining every skill. Since such athletes may not be able to read or write properly, or even differentiate between limbs well, a coach needs to explain many times until they know what to do and how to execute every skill.
Athletes with LD or intellectual disabilities will have certain levels of ability. It is preferable not to make assumptions about what they can do or cannot do, as each athlete has their own unique ability. Some even may have additional impairments such as hearing impairments. As a coach, it is important to make sure that the levels of instruction and direction that can be understood by your intellectually-challenged athletes are provided. This can be done through the use of simple, brief, concise language, while avoiding the use of jargon and complicated language. It is also suggested that coloured ribbons are used to differentiate between athletes` left and right hands. For example, you may tie different coloured ribbons to their hands and clarify that the red ribbon is on their left hand, and the blue ribbon is on their right hand.
Athletes with hearing-impairment
Athletes with hearing-impairment have the physical ability to perform running, jumping and throwing motions. However, frequent demonstrations are very useful for training and a coach should instruct these athletes to repeat the desired motions to ensure understanding of correct technique or skills that they are taught. Using peers/partners to demonstrate skills to them would be an ideal way to help them understand and learn new skills. Because of their hearing-impairment, some movement that involves balance may be affected and this should be considered by a coach when designing training programmes. A coach should also remember to teach the athlete to use flag or light or cues such as writing on a piece of paper, books, whiteboard, or even writing imagery on hands to show or communicate the right way to perform particular skills. Learning sign language by a coach is not necessary but knowing some important cues would make it easier to undertake training sessions. Using methods such as video recording, interpreters, illustrations and pictures would be beneficial for a coach to train the hearing-impaired.
A coach should learn to recognise non-verbal cues such as posture, facial expressions, gestures and movements and also observe the athlete`s response to instructions, explanations, and/or demonstrations to help them learn new skills. During verbal communication, a coach should position himself or herself so that the athlete can see them. A lot of messages can come from a coach`s facial expressions and body movements. The message should be clear, concise and presented in an interesting manner through demonstrations or sign language. Modeling can also be a good way to teach skills to enhance the performance of athletes with hearing-impairment, by instructing them to observe quality performances by others. It is better for a coach to allow athletes a few minutes to observe new drills from a model and try to ensure that you use competent models so that the athletes copy the desired movements or drills effectively. A coach should avoid or reduce some activities that focus on movements such as agility and balance since balance may be affected due to their disability.
Performance enhancement
Satisfaction with performance appears to be of vital concern to athletes with physical disabilities. To date, most research is performed by biomechanists, particularly those interested in wheelchair propulsion. Higgs (in Gehlsen, Davis & Bahamonde, 1990) found that proficiency in wheelchair racquetball corresponded with `greater distances covered per rally, greater wheelchair speed and a higher degree of maneuverability”. He also stated that peak velocity of a hand-pushed wheelchair is influenced by a variety of interrelated factors, including stroke frequency, range of contact of the handrim and the percentage of time in contact with the handrim. It also appears that the greater the stroke frequency, the greater the range of contact on the handrim, and the less time in contact with the handrim, the greater the peak velocity of the wheelchair. Another study by Gehlsen (in Fox, 2000) demonstrated that changes in trunk position produced greater peak velocity among wheelchair athletes.
Conclusion
Most of the suggestions in this article are not intended to offer complete explanation or detail techniques for coaching athletes with disabilities. There are many things that coaches have to consider and acquire knowledge on through research and education that would be ideal for them to help athletes with disabilities to improve their performance. Most of the research findings are on able-bodied athletes and coaches may not be able to apply these findings directly to athletes with disabilities. It is, therefore, important for coaches of disabled athletes to find aspects of the available research on able-bodied athletes that they can transfer into sport programmes for athletes with disabilities. Research related to sport and physical activity offers important, practical information for people with disabilities to enjoy and excel in sports. People with disabilities should be able to choose to participate in separate or parallel sports and leaders or coaches of these activities must be kept informed about scientific developments in training of disabled athletes to help them improve their competitive performance.
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Contact
Nagoor Meera Abdullah
Faculty of Sports Science and Recreation,
University Technology MARA, Malaysia
Shah Alam, Malaysia
Email: nameera_ab@yahoo.com.my

http://www.icsspe.org/