Wrestlers with Limb Deficiencies: A Descriptive Study Mike Baria, MD/MBA

State of the Science Symposium: Adaptive Reconditioning for Wounded, Injured and Ill

Veterans

June 5, 2015

Authors & Acknowledgements

Authors: Baria MR, Terry MJ, Driscoll SW, Andrews KL, Soma DB,

Prideaux CC

Citation: Wrestlers with Limb Deficiencies. Am J Phys Med Rehabil. 2015 Apr 16

Special thanks to Dr. Ralph Gay for manuscript review & Nick

Ackerman, CP Director of Prosthetics at American Prosthetics and

Orthotics (IA)

Financial Disclosures

Archbishop Moeller High School (Cincinnati, OH) provided funding

for participant remuneration

Introduction: Definitions

Our study uses the terms ‘impaired’ and ‘non-impaired’ in lieu of

‘disabled’ and ‘able-bodied’

Consistency with WHO definitions

Best descriptors

Our study uses the term ‘limb-deficient’ for both amputations and

congenital limb deficiency

Introduction: Limb Loss in the Military

According to the Army Office of the Surgeon General, there were

1,286 amputations in Operation Iraqi Freedom, Operation Enduring Freedom and other unaffiliated conflicts1

935 were considered ‘major’ limb amputations

Only 105 continued as active duty, reserves or were Fit for Duty

50% were caused by IEDs

77% Army, 19% Marines, 2% Air Force, 2% Navy

Limb Loss in the Military: What’s the

Burden?

The Military Extremity Trauma Amputation / Limb Salvage (METALS)

Study 2 reported

38.3% had a positive depression screen, 18% had a positive PTSD screen

34% were not working, active duty or enrolled in school

38% involved in rigorous sports / recreation

Many struggle with emotional health and have difficulty re-initiating

their social and vocational roles

Toward a Solution

In addition to foundational rehabilitation services, sports (competitive or

recreational) can help improve functional independence, mental and physical

health, and self-efficacy3,4

Common sports for limb-deficient athletes include track, swimming, sitting

volleyball, sled hockey and wheelchair sports

Though these are excellent options, each of them requires adaptive equipment

and / or competition against similarly impaired peers

My personal observations suggested that wrestling presents a unique opportunity for limb-deficient athletes by integrating them into standard

competition against non-impaired athletes

Background

The wrestling community has consistently seen limb-deficient wrestlers

compete against non-impaired peers

No adaptive equipment, accommodations, or disability classifications

Examples

https://www.youtube.com/watch?v=c5W4RZq1NRg

https://www.youtube.com/watch?v=Ri8kx2yEPMI

https://www.youtube.com/watch?v=4isX2EMMg08

From our best observations, competitive equality between the wrestlers is preserved

There are numerous success stories of limb-deficient wrestlers

Dustin Carter (Hillsboro, OH); 40-3 senior year record

Nick Ackerman (Simpson College); DIII NCAA Champion &

Hodge Trophy Winner

Rohan Murphy (Penn State)

Kyle Maynard (Collins Hill, GA): High School State Champion

Zach Anglin (Bayfield, WI): State Tournament Qualifier

Anthony Robles (Arizona State): DI NCAA Champion

Background

Despite this success, wrestling has not yet been integrated into

common athletic considerations for limb-deficient athletes and

participation remains isolated

Not found in any text, paper or website for impaired / amputee athletes

Wrestling is just not commonly considered for limb-deficient athletes

But maybe it should be

Aims

Since the rehabilitation, adaptive sports, and amputee communities

have limited awareness of wrestling as an option for limb-deficient

patients…

The primary goal of the study was to survey wrestlers with limb deficiencies to determine if wrestling is a safe and positive athletic

option for limb-deficient athletes

If safe and positive, we hoped to raise awareness of the suitability of

wrestling for these athletes

Study Design

Questionnaire-based descriptive study using a nationally distributed

electronic survey after receiving IRB approval

Inquired about demographics, limb loss etiology, achievements, quality

of life, barriers to entry, residual limb and musculoskeletal (MSK)

problems

Inclusion criteria: 5 years old and up, minimum 1 year wrestling

experience, limb deficiency at or proximal to the transradial / transtibial

level

Descriptive statistics used for analysis; Fisher’s exact test used to examine residual limb complication risk factors

Results: Demographics n=16 (50% response rate)

Gender Male: 16

Congenital vs. Acquired Congenital: 9

Acquired: 7

Age at Acquired Amputation (years) Median: 6

Range: 1-15

Acquired Etiology Traumatic: 4

Infectious: 3

Limb Deficiency Level Below Knee: 9

Above Knee: 5

Below Elbow: 3

Accomplishments

NCAA Champions 2

NCAA Tournament Qualifiers 2

Collegiate Wrestlers 7

Results: Wrestling-related residual

limb complications

Rate 50%

Complication Type Total #

Skin breakdown 6

Residual Limb Pain 5

Swelling 2

Phantom Pain 2

Infection 1

Results: Musculoskeletal Injuries

Significant injury defined as any injury that withheld the athlete from

competition

6 / 16 reported at least 1 significant musculoskeletal (MSK) injury

MSK Injuries by body region

Shoulder: 2

Elbow: 1

Low back: 3

All lower limb deficiencies

Knee: 3

*One respondent accounted for 4 injuries, while the others each had only 1

injury

Results: Training habits 9 used a prosthesis for cardiovascular / strength training

None used a prosthesis for wrestling training or competition

1 used modified grips for strength training; otherwise, no adaptive equipment needed

Results 100% indicated that wrestling had a ‘very positive’ impact on quality-of-

life

95% reported a ‘very positive’ impact on physical health

87% reported no difficulty finding acceptance with teammates,

coaches and competitors

Discussion: Competitive Equality

Limb-deficient wrestlers can and do succeed against non-impaired peers

without the need for accommodations or adaptations

No other sport boasts this degree of competitive equality

Competitive equality is likely fostered by the weight class system & nature of the

sport

Discussion: Competitive Equality

Because of the weight class system, whatever mass is absent from the limb is

redistributed to the torso and intact limbs

Competitive Equality or Competitive Advantage?

Basic concepts can guide our discussion

Competitive Equality or

Competitive Advantage?

Consider the wrestler with a lower limb deficiency

Upper body likely stronger than opponents: relative, not absolute, advantage

Missing a lower limb means an entire array of techniques are unavailable to

that athlete

Basic attacks requiring a powerful push-off, trips and throws

Mat mobility is challenging

These wrestlers must cope with and overcome significant challenges to be

competitive

Discussion: Injuries Residual limb complications seem common

Direct end bearing and shear forces

Complication rate of 50% warrants educating & monitoring the athlete;

meticulous skin care is a priority

Discussion: Injuries

MSK injury risk

For ‘all injuries’, rate was 38% all-time compared to 50% injury rate per

season in a large cohort of high-school wrestlers5

Wrestlers with lower limb deficiencies may be predisposed to low back

injuries

Altered biomechanics and their kinetic chain

Discussion: Injuries

Discussion

Wrestling was a markedly positive experience

Barriers to entry are low, allowing for easier integration

No special equipment, financial investment, personnel training or

adaptive needs

Limitations Selection bias

Small sample size

No female participants

Conclusion

This study suggests that wrestling is a safe, positive athletic

experience that provides the unique opportunity for competitive

equality between limb-deficient and non-impaired athletes

Wrestling should be integrated into the common athletic

considerations for athletes with limb deficiencies

Future Directions: Research

Detailed, prospective assessment of injuries

Specific etiologies

Motion analysis for injury prevention and optimizing training

Prospective study of mental and physical health outcomes

Preventive strategies for residual limb complications

Future Direction: Participation for

Military Amputees

Two groups: those with a wrestling background and those without

For those with experience, options include:

Post-college, join local sanctioned USA Wrestling club, help at local HS

http://www.teamusa.org/usa-wrestling/membership/athletes/find-a-club

If they plan to attend college, contact coach at the school

For those without experience, no clear opportunities exist

Local clubs may work, but not suited to new adults

Military programs are for elite level

Future Direction: Participation for

Military Amputees

Start a wrestling reconditioning program specifically geared towards

veterans with amputations

Need mat space and a coach

Contact myself or USA Wrestling: lgutches@usawrestling.org

References 1. Fischer H. United States Military Casualty Statistics: Operation Iraqi

Freedom and Operation Enduring Freedom. Congressional Research

Service. CRS report for Congress. March 25, 2009.

2. Doukas WC, Hayda RA, Frisch HM, et al. The Military Extremity Trauma

Amputation / Limb Salvage (METALS) study: outcomes of amputation versus

limb salvage following major lower-extremity trauma. J Bone Joint Surg Am.

2013 Jan 16;95(2):138-45.

3. Fiorilli G, Iuliano E, Aquino G, et al. Mental health and social participation

skills of wheelchair basketball players: a controlled study. Res Dev Disabil.

2013 Nov;34(11):3679-85

4. Pepper M, Willick S. Maximizing physical activity in athletes with

amputations. Curr Sports Med Rep. 2009 Nov-Dec;8(6):339-44

5. Pasque CB, Hewett TE. A prospective study of high school wrestling

injuries. Am J Sports Med. 2000 Jul-Aug;28(4):509-15

Photo Credits http://www.superiortelegram.com/sports/tigers/3651945-tiger-matmen-beat-bears-finish-sixth-spartan-classic. Jan 12, 2015. Accessed May 27, 2015.

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Questions & Discussion

baria.michael@mayo.edu