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Rolling
Forward: How Wheelchair Basketball’s
History, Progression, and Dynamic Influence
Have Impacted Spinal Cord Injury Rehabilitation:
Physically and Psychologically
by Monique
Jackson; msjakson@ufl.edu,
Undergraduate Student, University of
Florida, Gainesville, FL
Background Information
The spinal cord is essential to life
due to its three principle functions:
1) sensory and motor innervation of
the entire body inferior to the head,
2) two-way communication between the
body and the brain, and 3) a major center
for reflexes. (11) Any disruption to
this pathway due to some type of trauma,
either directly to the spinal cord or
indirectly, caused by damage or swelling
of the surrounding tissue that puts
debilitating pressure on the spinal
cord (Figure 1), will result in a less
than optimal quality of life. Both instances
can be easily avoided, but also experienced
with the same ease. This is due to the
anatomy of the spinal cord, which in
a living individual has the consistency
of a ripe banana, causing it to be easily
bruised, torn, or crushed with any significant
damage causing permanent injury, known
as paralysis;
and resulting in permanent change in
normal motor, sensory, or autonomic
function. The body parts that are affected
are those below the lesion, and depend
on the type of lesion: either complete
or incomplete (Figure 2). According
to Stopka and Torodovich, “A ‘complete’
injury means that all motor and sensory
function from the lesion down has ceased.
An ‘incomplete’ injury implies
that some motor and/or sensory function
remains intact” (8, p17).
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History of Wheelchair Basketball
The history of human experience with
spinal cord injuries
(SCI) has been a complex and dynamic
one; enshrouded in a cloak of doubt
of the future, depression of the present,
and anguish of missing one’s past.
Yet, the tales of time have had a parallel
of these experiences with ways to combat
and counteract the transformation that
they bring upon people. Many of these
tales find their biggest moments to
have occurred as a result of World War
II (WWII), in which great numbers of
young men enlisted in the military suffered
traumatic injuries that resulted in
paralysis. These soldiers needed ways
to combat the prevailing thought of
the time that “nothing can be
done for these young men” to fight
back toward leading a fulfilling life
in every aspect of society. Wheelchair
basketball became an indispensable
rehabilitation tool affecting both physical
and psychological troubles for those
with SCI during the war and well into
the future.
Sir Ludwig Guttmann’s
Impact
During these times, complications that
followed SCI, such as malfunctions of
the kidneys and bladder, as well as
infected bed sores, were thought to
be ordinary hardships along the inevitable
road to death. However, there was one
courageous and hardworking doctor who
worked tirelessly to combat “this
defeatist attitude” (3) and his
name was Sir
Ludwig Guttmann. What gave Dr. Guttmann
the passion to pursue routes that could
combat the defeatist attitude was his
time serving as an orderly in WWII,
in which he saw a patient, a well built
and strong looking man, brought in and
placed at the end of the ward, and surrounded
by screens in an attempt to make his
dying days, weeks, or months private
and more bearable. This prompted in
Dr. Guttmann the need to overcome the
defeatist attitude toward SCI, and formed
his personal philosophy “that
these complications could not only be
controlled but altogether avoided”
(3).
Later on during WWII Dr. Guttmann,
who quickly rose to the top of his field
of neurology and became a renowned brain
surgeon, fled from Nazi Germany to Great
Britain to work at The Spinal Rehabilitation
Hospital in Stoke, Mandeville, where
he developed wheelchair netball to aid
in the rehabilitation of veterans. There
Dr. Guttmann became conscious of the
fact that not only did those with paralysis
face physical problems, but also mental
and social psychological problems; particularly
in the veterans he worked with he noticed
societal withdrawal and depression.
This was another innovative thought
on his behalf that led him to form rehabilitative
programs that worked to not only help
prolong life, but also to fight the
psychological factors, and help to assimilate
the young men as useful and respectful
members of society.
Dr. Guttmann worked towards these goals
utilizing sports for he believed it
“would encourage them to make
the most of their remaining physical
capabilities, provide much-needed exercise
and restore mental equilibrium”
(3). From then on Dr. Guttmann enforced
mandatory participation in athletic
and physical activities while patients
with SCI were staying at the Stoke facility.
The program utilized therapeutic qualities
of physical activity that allowed veterans
to regain their coordination, strength,
and confidence to find available jobs,
and regain a self-fulfilling role in
society once more. Consequently, the
mandatory participation led to competition
amongst the patients and the hospital
staff, resulting in the first Stoke
Mandeville Games for the Paralyzed,
which was held on July 16, 1948, the
same day as the Olympics.
The rehabilitation to this sequence
of events is inherent, in that it made
the patients active and physically engage
their bodies. Yet, it must also be noted
the psychological benefit that the competition,
especially the Stoke Mandeville Games,
had on the patients who went from being
bed-ridden and possibly on their deathbed
to inclusion in “regular”
activities and games that showed them
their physical ability and potential.
It is apparent that not only did Dr.
Guttmann’s programs have a physical
benefit, but they also helped to rework
the psyche, as was acknowledged by one
patient in particular who was quoted
as having said: “We’re so
busy in this bloody place we haven’t
got time to be ill” (3).
National Wheelchair Basketball
Association
At approximately the same time Dr. Guttmann
was working to use sports and netball
as a therapeutic tool in Great Britain,
there was a similar movement in America.
Wheelchair activities and sports started
as a way for WWII veterans with paralysis
to become active once again. Initial
sports ranged from ping-pong to volleyball,
and finally to fast paced sports such
as touch football and basketball. Credit
for the creation of wheelchair basketball
is not clearly identified, but has been
generally shared between the California
and New England chapters of Paralyzed
Veterans of America (PVA). Both
agree that the game got its start circa
1946, and with popularity spread across
New England and the Midwest and then
onto Canada and across the pond to England
(1).
By 1948 there were six teams that operated
out of Veteran’s Administration
(VA) hospitals that participated in
the PVA tournament. The first “civilian”
team, or team not affiliated with a
VA hospital, was the Kansas City Wheelchair
Bulldozers, later called the Rolling
Pioneers. This was monumental, yet the
PVA tournament was still very exclusive,
open only to veterans with paraplegia
or SCI. Not surprisingly this exclusive
tournament eventually folded to the
more inclusive and tougher competition
of the National Wheelchair Basketball
Association (NWBA) in 1948. The inclusiveness
of the NWBA speaks volumes of how it
helped in the psychological development
of current participants, and the newcomers
who previously may not have had any
other way to engage in an activity that
disregarded the fact that they are wheelchair
bound or enabled them to be physically
active. The mission of the NWBA is:
“In our pursuit of excellence,
the National Wheelchair Basketball Association
provides qualified individuals with
physical disabilities the opportunity
to play, learn, and compete in the sport
of wheelchair basketball” (1).
Tim Nugent’s Impact
A principal organizer of the NWBA, and
a leader in the use of the sport as
a rehabilitation tool is Tim
Nugent, the former Director of Rehabilitation
at the University of Illinois (UI).
In 1949, along with a group of UI students,
Nugent formed the first NWBA tournament
in which six teams played. The tournament
resulted from an effort to provide Nugent’s
team, the Illinois
Gizz Kids, with outside competition.
Like Guttmann, Nugent saw the psychological
and social void from paralysis that
wheelchair basketball filled: “The
heart and skill shown by participants
in wheelchair basketball will soon remove
the apathy which has surrounded the
so-called physically handicapped, and
force people to see the whole scope
of life, what can and needs to be done.
It is my hope that wheelchair basketball
will remain a game of the boys who need
it and want it" (7).
The NWBA grew immensely while Nugent
served as its first Technical Director
& Commissioner, fulfilling his role
to organize and administer the affairs
of the association. Nugent continued
the game’s connection with the
military by working with the United
States Armed Forces to utilize military
airlifts "to provide transportation
for needy member teams that had no formal
sponsorship or other revenues to get
them to the annual national delegates
meeting and championship games”
(7). His ability and efforts in working
with the military also provided a home
for the association’s annual events
at military bases located around the
country. Nugent’s work ensured
an annual representative forum to guarantee
participants’ involvement in the
decision making process. As Technical
Director & Commissioner, Nugent
introduced legislation that would regulate
the types of disabilities that could
play against one another resulting in
the functional ability point system.
This allowed for even matched play,
preventing a team from stacking athletes
with less severe disabilities against
athletes with more severe disabilities.
According to the International Paralympic
Committee the point system is set: “Depending
on their functional abilities a point
value from 0.5 (most severely disabled)
to 4.5 is given to each player. Five
players out of 12 from each team are
on the court during playtime, and throughout
the game the total point value of each
team must not exceed 14 points”
(2). Wheelchair basketball’s ability
to bring inclusion to a group that was
often separated from society is due
to the game’s similarity of regulations
to that of the able-bodied version of
basketball. As aforementioned the association
grew under Nugent’s guidance and
a number of powerhouse teams and dynasties
emerged throughout the years. Due in
large part to the tireless efforts of
Tim Nugent, the NWBA is regarded as
the standard for all organizations for
persons with disabilities.
PROGRESSION OF THE GAME
International Play
Even with all of his endeavors in America,
Nugent played a major role in the international
sector as well by negotiating and formulating
plans with other sport leaders, such
as Dr. Guttmann, to bring wheelchair
sports to the international level. This
resulted in wheelchair basketball being
played in the 1st Paralympic Games in
Rome, Italy in 1960. Now internationally,
those living with paralysis were able
to train, be physically active on a
daily basis, have regular interaction,
and utilize every therapeutic aspect
the game had to offer. Presently a kingpin
in international competition is the
World Championship, formerly known as
the Gold Cup Tournament. This groundbreaking
competition was the first for international
sport to allow people with amputations
and other non-SCI athletes to compete.
Women’s Introduction
into the Game
According to NWBA historian Stan
Lebanowich, the women’s game
was ushered in by the birth of the University
of Illinois’ Ms. Kids (another
resource) during the 1970s, whose
program was built by the athletes playing
able-bodies athletes (1). The women’s
game followed the same trend the men’s
game did to grow from a few teams and
nations dominating game-play and championships
to the creation of the USA’s National
Women’s Wheelchair Basketball
League in 2000.
Rehabilitative Effects from
Wheelchair Basketball Participation
Wheelchair basketball is a sport, under
any definition of the word, and like
any other sport participation in this
one requires training, which effects
strength and conditioning, which in
turn effects rehabilitation. This was
and still is doctors’ number one
motive when it comes to encouraging
patients with SCI to be physically active
and participate in sports. There have
been great strides in studies and research
to produce knowledge and information
regarding the rehabilitative effects
of participation in wheelchair basketball
towards both the physical and psychological
realm.
Strength & Conditioning/Physical
As far as the physical aspect is concerned,
studies have shown that just because
athletes may be in a sedentary position
it does not mean they should not utilize
and incorporate strength and conditioning
training. Training should be used as
both a part of their continuous rehabilitation
and preparation for sporting events.
There is no exception to the fundamental
rule that functional stability must
be increased before minimal loads, such
as the push required to propel a wheelchair,
or plyometrics
are incorporated. Both of these must
be applied to all wheelchair athletes.
One must remember, however, to regard
different functioning capabilities by
tailoring programs to specific athletes.
Experts strongly recommend for individuals
with adapted needs to regularly engage
in weight training activities to prevent
debilitating sequelae.
An effective weight training program
should include the following seven integral
components: 1) number of repetitions
to be performed, 2) numbers of sets
to be performed, 3) workload, 4) time
interval between exercises, 5) workout
frequency, 6) exercises to be performed,
and 7) exercise sequence (9). Research
has concluded that an adaptive weight
training program for athletes with disabilities
should include the objectives of strength,
endurance, and flexibility. Furthermore,
general criteria for a weight training
program should follow these guidelines:
regarding strength, “identify
the individual’s maximum weight
for the specific exercise that can be
lifted ten times in a row. Then, the
strength program will consist of lifting
50% of maximum weight for ten repetitions,
75% of maximum weight for ten repetitions;”
make certain the athlete utilizes progressive-resistance
exercise and have them perform three
sets a day, three times a week; as for
endurance “identify the individual’s
weight for the specific exercise that
can be lifted 50 to 100 times in a row.
Then the endurance program will consist
of lifting the maximum weight possible
for 50 to 100 times in a row, without
pain, etc.;” and finally for flexibility
have the athlete move the joint through
full range of motion without experiencing
pain (9, p200).
As with any other athlete an initial
assessment should be done to determine
the physiological profile, and to test
the different aspects of muscular strength,
sport specific flexibility, endurance,
power, balance, posture, and aerobic/anaerobic
energy systems. According to Ramsbottom,
“Wheelchair athletes need a great
deal of neuromuscular and core training
to help with stability, posture, coordination,
reflexes, and the transfer of power
during movement. The goal of neuromuscular
and core training is to stimulate the
nervous and muscular systems to create
a stable foundation to move from. The
core, the center of gravity of the body
located around the navel, should be
this foundation. Due to the nature of
a wheelchair athlete's movement patterns,
special attention must be made to strengthening
the posterior musculature. These upper
back muscles ensure muscle balance between
the anterior and posterior sides of
the body. Proper muscle balance will
help to maintain efficient movement
and allow for maximum power production”
(5).
It is common knowledge of the effects
that weight training has on bone structure
by helping to increase the density of
the bone. Studies have shown that radial
bone density is higher in wheelchair
athletes compared to their sedentary
counterparts with paraplegia. In recent
years, sports for athletes with physical
disabilities are gaining popularity
in Japan for its value in maintaining
and improving remaining functional abilities
and increasing independence and motivation
for life (6) Table 1. “Exercise
has also been proven to increase serum
levels of bone formation markers in
humans. These data support our findings
in which BMD [body mass density] of
the legs, body trunk, and entire body
among wheelchair athletes who restarted
sports activity immediately after SCI
injury was observed to be higher than
those who restarted their sports later”
(7) (Table 1).
Another study investigated the acute
changes in the bicep tendon after a
high-intensity wheelchair propulsion
activity. One aspect of this study showed
that, with respect to the participant’s
playing time, there was a change in
tendon diameter that reflected a positive
correlation. To put this simply, those
who participated for greater time periods
experienced a larger change in tendon
diameter than those who participated
for a shorter time period (12) (Figure
3).
Psychological
The psychological benefits of wheelchair
basketball can be witnessed on a superficial
level that can be experienced through
interaction with individuals with SCI,
and from listening to their reflections.
Yet, there are only a few studies that
have delved deep into investigating
this realm, where research has shown
that individuals with disabilities that
participate in activities and remain
physically active exhibit better mood
states, less stress, and greater functional
capacity and strength as compared to
their less active counterparts (10).
One particular study shows that an “interpretation
of the quotes and data reported by Taub
et al. was that the participants [in
a qualitative interview] appeared to
develop a sense of competency and skill
that allowed them to demonstrate to
others they were not sick or diseased
and could function similar to others”
(10). Consequently, an interpretation
held by many in the field is that the
psychological rehabilitative effect
wheelchair basketball has is that it
gives participants a feeling of inclusion
when meeting new people and expanding
their social interactions, greater strength,
less restrictions in their environment,
and awareness of improved health and
self-perception. All of these things
are necessary to have a stable mind
and body.
Conclusion
Inarguably, wheelchair basketball has
become an indispensable rehabilitation
tool affecting both the physical and
psychological concerns for those with
SCI. This has been witnessed from its
initial utilization during World War
II to its ever changing effects in the
present that will unquestionably continue
into the future. Wheelchair basketball
began as a way for soldiers to combat
the war era thought of “nothing
can be done for these young men”
to fight back toward leading a fulfilling
life in every aspect of society, and
its work continues today with the same
occurrence due to the Wars in Iraq and
Afghanistan. Appreciation and gratitude
must be give to the men, women, and
doctors who paved the way for those
to roll across the court today. So much
is to be gained from this sport due
to its physical and psychological rehabilitative
factors of strength, coordination, endurance,
a sense of cohesion and bond among teammates,
and the most important-the feeling and
knowledge that disability does not equal
inability.
REFERENCES:
- Lebanowich S. History of Wheelchair
Basketball. National Wheelchair Basketball
Association Web Site. 2007. Available
at: http://www.nwba.org/index.php?option=com_content&view=article&id=13&Itemid=120.
Accessed April 13, 2009.
- Wheelchair Basketball. IPC, International
Paralympic Committee Web Site. 2009.
Available at: http://www.paralympic.org/release/Summer_Sports/Wheelchair_Basketball/.
Accessed April 14, 2009.
- Jan Godfrey & Marilee Weisman.
A History of Wheelchair Sports: Sir
Ludwig Guttmann. Available at: http://www.spitfirechallenge.ca/Sir%20Ludwig%20Guttmann%20early%20history.htm.
Accessed April 15, 2009.
- Sports Science Committee. IPC, International
Paralympic Committee Web Site. 2009.
Available at: http://www.paralympic.org/release/Main_Sections_Menu/IPC/Organization/Standing_Committees/Sports_Science_Committee/index.html.
Accessed April 15, 2009.
- Ramsbottom S. Strength and Conditioning
Principles for Wheelchair Athletes.
- Miyahara K, Wang D, Mori K, Takahashi
K, Miyatake N, Wang B, Takigawa T,
Takaki J, and Ogino K. Effects of
sports activity on bone mineral density
in wheelchair athletes. Journal of
Bone Mineral Metabolism. 2008; 26:101-106.
- Timothy J. Nugent. National Wheelchair
Basketball Association Hall of Fame.
Available at: http://www.nwbahof.org/TNugent.cfm.
Accessed April 15, 2009.
- Stopka C & Todorovich J. Application
of Principles and Concepts: Physical
Disabilities. In: Applied Special
Physical Education and Exercise Therapy.
Boston, MA: Pearson; 2008: 17.
- Stopka C & Todorovich J. Therapeutic
Weight Training. In: Applied Special
Physical Education and Exercise Therapy.
Boston, MA: Pearson; 2008: 199-201.
- Giacobbi Jr. PR, Stancil M, Hardin
B, and Bryant L. Physical Activity
and Quality of Life Experienced by
Highly Active Individuals With Physical
Disabilities. Adapted Physical Activity
Quarterly, 2008, 25, 189-207.
- Drongelen S, Boninger M, Impink
B, and Khalaf T. Ultrasound Imaging
of Acute Biceps Tendon Changes After
Wheelchair Sports. Archives of Physical
Medical Rehabilitation. 2007; 88:381-385.
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