Perspectives – Wayne Derman, South Africa

After eight years and two Olympic games as Chief Medical Officer of the South African Olympic Team, I was assigned as team physician to the South African Paralympic team. My response, in brief, was some serious kicking and screaming! After all, I was an Olympic doctor! My expertise was in ‘elite sports’, not suboptimal performances of the ‘supercrips’! After my disappointment had subsided, a colleague who had previously been a medical officer to a Paralympic team advised me that the best possible thing for me would be to experience a Paralympic Game. I listened to his opinion and absolutely ungraciously accepted the position.

In short I am so grateful that I did. Through my role as Paralympic team physician I was able to grow academically, clinically as a physician and emotionally as a human being. Let me explain.

Firstly, as a clinician. I realise that the ability to have a meaningful role in overseeing men’s desire to be a better version of themselfs is what attracted me into medicine. To play a role in the journey from disease back to health. Why I was drawn to sports medicine is slightly more complex. I wanted to do it all and the fact that sports medicine encompassed both orthopaedics and internal medicine was attractive. The fact that this was medicine at the extremes of physiology was even more appealing; studying men at speed, at maximal exercise, on top of the tallest mountains and at the depths of the oceans. What the Paralympics gave me was an extra layer of complexity, the layer of impairment or disability on top of all that! Now we are really talking about the ultimate clinical challenge!

KEY SIMILARITIES BETWEEN OLYMPIC AND PARALYMPIC ATHLETES

·      Both are the ultimate achievers in sports.

·      Both typify elite sports at the highest level – even the athletes with severe cerebral palsy playing boccia typifies sport at the highest level, with exercise at the extremes (heart rates in boccia players have been shown to be between 160 and 180 beats per minute for more than three hours).

·      Athletes are athletes; they will sacrifice everything to win and even make some bad decisions including taking illegal performance enhancing drugs or engaging in prohibited methods such as boosting.

SOME DIFFERENCES BETWEEN OLYMPIC AND PARALYMPIC ATHLETES

·      An understanding of many clinical syndromes and causes of impairment is required to understand the impact on human performance.

·      As the spectrum of medical issues is different, a wide knowledge of medical subspecialties is important, e.g. dermatology and wound care in athletes with spinal cord injuries or amputations.

·      Physicians are taught to always compare an injured limb or joint to the contralateral normal limb or joint. In some athletes with impairments there is often no ‘normal side’ for comparison.

·      The biomechanical impact of impairment can be huge. There are significant asymmetries in athletes with impairments, often leading to overloading of the sound side.

·      The team physician is required to have a basic understanding of the technical aspects of equipment including racing chairs and prostheses. Being able to think out of the box for quick fixes is an added skill that is useful as the team physician.

·      The spectrum of pharmacological agents required in the management of the athletes is vast and needs to be understood as it relates to performance and interactions with other drugs, as well as considerations for Therapeutic Use Exemptions (TUEs).

PERSPECTIVE, RESILIENCE AND HUMOUR

Perhaps the most lasting impression I have taken away from my work with Paralympians is an overwhelming sense of gratitude on behalf of the athletes. In my time travelling, I did not hear one complaint from a single athlete, not a word expressing difficulty, not a moan, not a grumble. On reflection, I think that the ability to deal with adversity is learnt through adopting a mindset, which is the gift of perspective. When one must face the most challenging circumstances that life may have to offer (often the cause of the disability) and have accepted and integrated that into one’s being, the blessing that remains as part of the psyche, is that of perspective. To generalise, I would say that Paralympic athletes clearly have the gift of being able to see the bigger picture and somehow do not seem to get caught up in complaining about the minutiae – I have met very few prima donnas.

Another striking observation is that of profound resilience in the characters of these athletes, as well as an excellent sense of humour. Working with Paralympic athletes has made me realise that the key to resilience is indeed humour, the most important component of emotional intelligence. These athletes are experts in their self-depreciating humour; displaying an uncanny ability to laugh at oneself. If one can laugh at oneself, the ego is removed or suppressed and when the ego has been reduced, this allows one to be fully present and fully engaged with the task at hand, in many instances this means the competition and excellence in performance ensues.

On close observation, it seems that when the athletes who are victorious at the Paralympic Games make it to the podium to receive their medal and raise their hand or arm (or stump) in triumph, they stay there for a little longer than their Olympic counterparts, absorbing the applause. I have learnt that this is not due to any narcissistic tendencies or the physical inability to move quickly off the podium, rather, the medal and their presence on the podium represent a victory, not only in the race or event, but a victory of that athlete over their impairment and the various hurdles that come along with it.

PARALYMPICS VS OLYMPICS?

Although I went kicking and screaming to look after the Paralympic team, I realised in hindsight that this reluctance was perhaps my own lack of self-belief that I did not have what it would take to do this job. However, I have never looked back since. I love the medical side of Paralympic sport. It has become my focus area within my medical research and I have spent time serving on the International Paralympic Committee (IPC) Medical Committee, contributing to the health of the Paralympic athlete.

Without a doubt, the Paralympics are as competitive an event as the Olympic Games, however with an additional mission to raise awareness and provide a global perspective on the unique and remarkable capabilities of individuals with an impairment. Athletes with disabilities are just as dedicated, and train and compete equally as hard as their able-bodied counterparts. Yet, Paralympians often manage to see the bigger picture. As disappointing as losing a medal might be, many of these athletes have at some stage lost something much bigger in their life. Without a doubt, they will be back to compete again.

Perspectives – Cheri Blauwet, USA

In contrast to Wayne, my entry into the world of Paralympic Sports Medicine was a smooth transition and the result of a passion for Paralympic sport that had evolved over many years. As a person with spinal cord injury, I was first introduced to adaptive sport when I was 13 years old, growing up in a rural part of the United States. I had acquired my injury at 16 months of age as the result of a traumatic farming accident. Although I grew up in a supportive household, I had always assumed that my disability would prevent me from living an active lifestyle and I certainly never would have dreamed of labelling myself an ‘athlete’. All of this changed very quickly when our high school track and field coach invited me to join our able-bodied team. He had recently seen a wheelchair racing exhibition event and he wanted me to give it a try. At first, my response was a very firm “no – not interested!” However, after much cajoling, I showed up for practice, kicking and screaming.

What I discovered during that first year of training came as quite a surprise. With practice, my times began to drop. I acquired a racing wheelchair and clumsily learned how to steer it around the track. Within several months, I realised that not only did I have the capability to be an athlete, I also quite enjoyed competing and competing to win! Even more importantly, I met other successful, young athletes with disabilities who had interests and aspirations similar to my own. Sport provided an entry point for my discovery of the disability community and with it, role models who led me to a much higher level of independence and empowerment. Although still a teenager, I learned how to travel independently, carry luggage and sports equipment through an airport, go up and down escalators in my everyday wheelchair, fend for myself in challenging environments and laugh at myself when things didn’t go as planned. My grades in school started to improve and I became more confident. With time, I began to travel with a competitive team and had the opportunity to see the world outside of my small town. I embraced a new global perspective and began to see my disability as an opportunity rather than a detriment, providing a powerful platform for both athletic success, as well as changing societal views around ability.

Ultimately, I had the honour of representing Team USA in the sport of wheelchair racing at three Paralympic Games (Sydney, Athens, Beijing), bringing home a total of seven medals, as well as two wins at both the Boston and New York City Marathons. Throughout my time as an athlete, the Paralympic Movement progressed to new levels, enabling athletes to garner sponsorship support and public notoriety. As I approached retirement, I knew with certainty that the Paralympic Movement would always be a part of me. Indeed, it had shaped and continues to shape who I am as a person. Although I would no longer compete internationally, I had to find a way to stay involved!

Throughout my athletic career I had also progressed academically, through undergraduate studies and ulti-mately medical school at Stanford University. Soon after I retired from competing, I applied for residency in physical medicine and rehabilitation, followed by a fellowship in sports medicine. With time and the help of key mentors, I discovered that a nexus could be created, combining my experiences as an athlete with my newly evolved skills as a physician. A career in ‘Paralympic Sports Medicine’ was born!

In retrospect, I realise that one of the things I loved most about being a Paralympic athlete was that my performance on the field of play was not just about me – it was about being an advocate and telling the story of disability empowerment to audiences across the world, and promoting opportunities for the next generation. I loved the fight – not just to win, but also to gain recognition and respect, as an elite athlete.

Now, as a clinician, researcher and leader, it is still all about advocacy and fighting the fight. As the Chair of the IPC Medical Committee, I have the distinct honour of leading an amazing team of colleagues, working collaboratively to promote   and advocate for   the athlete health agenda within the Movement. As clinicians, we strive to advocate for the resources needed to optimise the health of the Paralympic athlete. As researchers, we strive to provide the evidence needed to garner those resources and educate programme development. As leaders, we set policy that protects the athlete’s rights as it relates to their health, ensuring fair play and safe sporting environments. None of this comes easily, particularly in settings with limited resources, however the fight must go on.

We truly hope that this Aspetar Sports Medicine Journal Targeted Topic on Paralympic Sports Medicine is interesting, informative and useful in providing you with the necessary tools for engaging with Paralympic athletes of all abilities. We look forward to engaging with you further as we work collectively to optimise the health and performance of athletes from all corners of the world.

Wayne Derman, M.B.Ch.B., Ph.D.

Institute of Sport and Exercise Medicine, Division of Orthopaedic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University

Stellenbosch, South Africa

International Olympic Committee Research Centre, South Africa

Cheri Blauwet, M.D.

Assistant Professor of Physical Medicine and Rehabilitation, Harvard Medical School

Director, Kelley Adaptive Sports Research Institute  

Spaulding Rehabilitation Hospital/Brigham and Women's Hospital

Boston, MA USA

Chair, International Paralympic Committee (IPC) Medical Committee

Member, International Olympic Committee Medical and Scientific Expert Group