2 Braces and wheelchairs

Many physically handicapped children who partici­pate in physical education programs use a wheelchair for locomotion or wear braces, and some children require both devices. The physical educator should have a working knowledge of the care and maintenence of lower extremity braces and wheelchairs. One of the teacher's responsibilities is daily observation of the student's use and care of ambulation equipment. In conjunction with related services, the child's class­room teacher, family, and physical educator should develop a program to maximize the use of ambula­tion devices in the physical education setting and be­yond the school boundaries. In addition, any prob­lems that arise with the ambulation devices should be communicated to the special or regular class teacher or the parents.

Leg Braces

Leg braces are metal or plastic support frames that are strapped to the body above and below specific joints to assist with ambulation. The main purposes of lower extremity braces are to support the weight for ambulation, to control involuntary movements, and to prevent or correct deformities.

In general, there are three classifications of lower leg braces – short leg braces, long leg braces, and hip braces.

Short Leg Brace

A short leg brace is appropriate when the dis­abling condition occurs at the ankle joint. Although there are several different types of short leg braces, the simplest form consists of a single metal upright bar attached to the shoe with a cuff around the calf of the leg. When more stability is needed, double upright bars are used. The design of this type of brace should facilitate the control of four movements of the ankle joint. Leather straps attached to the metal uprights and strapped around the ankle assist with control of the ankle joint.

Long Leg Brace

The long leg (knee-ankle-foot) brace assists with control of the ankle and knee joint. The fundamental purpose of the long leg brace is to prevent hyperextension of the knee caused by weak extensor muscles. The brace must be in different po­sitions when the student is sitting as compared to standing. To accommodate the different positions of the knee, various types of locks are placed at the knee joints, the most common of which is a sliding metal lock that is easily locked and unlocked by hand. The knee joint of the long leg brace is locked when the individual is sitting in a chair. Locking de­vices may also be used to control the ankle when this type of brace is used.

Long Leg Brace with Pelvic Band

The long leg brace may extend from below the ankle to above the hip. Such a brace is called a hip-knee-ankle-foot long leg brace. The purpose of such a brace is to control movements of the hip joint as well as the knee and the ankle. To assist with the control of the hip joint, a pelvic band is attached to the top of the upright bar.

The physical education teacher should have a working knowledge of the functions of leg braces.

Some of the characteristics that can be observed are as follows: (1) brace joints work easily, (2) brace and anatomical joints coincide, (3) upright conforms to the leg, (4) brace is of correct length, and (5) upright coincides with the midline of the leg.

Wheelchairs

The purpose of wheelchairs is to provide a means of locomotion for persons who lack strength, endur­ance, or flexibility of muscles prerequisite for ambu­lation. Persons who can walk but cannot rise from a seated position to a standing position or those who need to transport objects but cannot do so may also need a wheelchair.

There are several types of wheelchairs. However, the most common are made of metal and have four wheels. The two back wheels are large, and the two front wheels are small and mounted on casters that pivot freely. Two or more separate rims that can be grasped to propel the chair are mounted to the back wheels.

Wheelchair design is a continuous process, the goal of which is to make the wheelchair more func­tional. Many special features can be added to make a wheelchair more functional or comfortable, includ­ing armrests, footrests, legrests, and headrests, all of which can be removed. Leg spreaders have also been incorporated into some wheelchairs to prevent the scissoring of legs. There are motorized wheelchairs to accommodate persons who have severe afflictions of the upper extremities. Some other features of a wheelchair are unique folding mechanisms that allow it to double as a stroller or car seat, adjustable Velcro fasteners, pads, and attachable trays.

Specialized Adapted Seating

Adapted seating for severely disabled individuals has been a subject of increasing concern. Inappropriate seating of severely afflicted individuals can result in severe scoliosis with vertebral rotation. Severe contractures may result from fixed postures in a wheel­chair. To avoid this, extensive adaptations of the chair may be necessary. Hundertmark indicates that the anterior and posterior tilt of the pelvis and the verti­cal angle of the backrest are important considerations in achieving therapeutic seating for the severely multihandicapped person.

Adapted Sports Activity

Physically handicapped persons should develop skills that can be expressed in recreational activity' in the community. One of the desired outcomes of the ac­quisition of sport skills is participation in competitive sports. Therefore, the instruction in the physical ed­ucation program should match opportunities for sport participation in the community. The generaliza­tion of the sport skills acquired by the physically handicapped in the instructional phase of the physi­cal education program requires close study of several variables. Some considerations might be the nature of the specific disability, the equipment required for participation (wheelchairs and ancillary equipment), and ways of structuring competition to maximize ful­fillment for the individual.

Opportunities for Participation

Physically handicapped persons need opportuni­ties to express attained sport skills in competition. Many public schools have limited numbers of physi­cally handicapped persons of similar ages and ability. This makes organized competition difficult. There­fore, cooperative efforts need to be made among schools to provide opportunities for competition among the athletes. Special Olympics, in some states, provides this opportunity. Wheelchair sports events are staged for competition. Several colleges and uni­versities have intercollegiate wheelchair sports pro­grams. The University of Illinois has developed one of the best intercollegiate wheelchair sports pro­grams. Several other universities also have well-de­veloped intercollegiate athletic programs.

There are two national organizations for wheel­chair sports – the National Wheelchair Athletic Asso­ciation and the National Wheelchair Basketball Asso­ciation. The mission of both of these organizations is to promote competition in which persons confined to wheelchairs may participate. These organizations provide a forum and incentive to maximize proficiency in sports for competition. Higher forms of competition may be expressed at the International Sports Organization for the Disabled. Thus opportu­nities exist for many physically disabled individuals to participate in competitive sports at their ability-level with incentive to increase skills to a world-class level.

Nature and Scope of Program

Wheelchair sports are designed to accommodate persons with significant, permanent physical disabil­ity of the lower extremities that prevents full partici­pation with able-bodied peers. Persons who may be included in this group are those with cerebral palsy, muscular dystrophy, or spinal cord injuries. Many of these persons may not use wheelchairs but qualify for competition because of inability to engage in full participation with able-bodied peers.

The sports activity program involves sports that do not require use of the legs and can be performed from the wheelchair. Some of the sports activities of the National Wheelchair Athletic Association are tar­get archery, table tennis, swimming, weight lifting, and selected field events. Other activities for which adaptation can be made are fencing, bowling, bad­minton, volleyball, floor hockey, and miniature golf.

The purpose of the classification system is to allow for fair competition. Tests are administered to determine the level of muscular function. Such tests do not take into account the proficiency of the athletes in competition. Clearly, children in wheelchairs do not have equal abilities. Therefore, to provide equi­table competition in school-based wheelchair activi­ties it may be necessary to test skill performances and group the participants according to ability in the in­dividual sports.

Amputees are considered to possess a lesser hand­icap when compared with other athletes confined to wheelchairs. In some instances they play sports such as volleyball standing up. In efforts to equate com­petition they are classified according to the number of amputations and the location and the length of the stumps. Amputations may occur on one or both sides of the body, above or below the knees.

Another group of persons in wheelchairs have se­vere impairment of the upper appendages. They may have spasticity or contractures. It is not uncommon for these children to adopt unique throwing patterns to maximize performance. Their physical structure rules out the teaching of mechanically sound sport skill patterns. Specific techniques must be deter­mined for each child.

Adaptation of Equipment

The physical limitations of orthopedically handi­capped children are related to opportunity for participation in games. It may be necessary to adapt equip­ment to include children in sports activity. For in­stance, there are several commercially available pieces of equipment that enable handicapped per­sons to participate in bowling. Some of the adapta­tions are a bowling bowl with handles, a fork that allows the handicapped person to push the bowling ball as in shuffleboard, and a ramp that enables grav­ity to act on the ball in place of the force provided by movement. Mach of these adaptations in equip­ment accommodates for a specific physical problem related to bowling. The adapted equipment for bowl­ing is paired with the nature of the physical problem.

Assessment of Skills Needed for Participation Many children with severe physical handicaps can engage in games and sports with few adaptations. Most can enjoy swimming activities. However, per­sons restricted to wheelchairs should be appraised to determine their functional movement capability. Mo­tor programs should then be developed to meet their unique needs. The assessment should provide infor­mation about the potential for movement of each ac­tion of the body. This would involve knowledge of strength, power, flexibility, and endurance of specific muscle groups. In addition, there should be infor­mation about which movement actions can be coor­dinated to attain specific motor outcomes. For in­stance, several throwing patterns that children with severe impairments use when participating in the Special Olympics can help circumvent movement problems of the arms and hands. The desired throw­ing pattern is one of extension of the arm and elbow and flexion of the wrist. If either of these actions is impaired, alternate throwing patterns need to be found. Some throwing patterns developed to circum­vent extreme disability of arm, elbow, and wrist are underhand movement, horizontal abduction of the arm/shoulder, flexion of the arm and elbow (over the shoulder), horizontal abduction of the arm (side arm), and overhand movement with most of the force from a rocking motion of the trunk. To maxi­mize the potential of each of these types of throwing patterns, it is necessary to conduct training programs that will consider each child's assets and develop them fully. However, another option is to provide therapeutic exercise for each ot the desired actions and then teach it as a functional, normalized move­ment pattern.

The ability prerequisites of strength, flexibility, en­durance, power, and coordination can be applied to many wheelchair activities. Some of these activities involve (1) transfer skills from and to the wheelchair, (2) performance on mats, (3) performance on gym­nastics apparatus, (4) ability to maneuver vehicles, (5) motor capabilities in a swimming pool, (6) walk­ing with aids, and (7) the ability to push and pull objects. The ability prerequisites for each fundamen­tal movement pattern should be studied to identify specific problems so that appropriate intervention can be undertaken.