London bridges: Clinicians and athletes connect at the 2012 Paralympic Games

Unbridled enthusiasm from record-breaking crowds helped motivate athletes—and the medical professionals supporting them—to new levels of performance, according to both competitors and practitioners who went to London for the 2012 Paralympic Games.

The games, held August 29 through September 9, were the best-attended Paralympics in the event’s 52-year history, with more $70 million in tickets purchased by 2.7 million spectators.

“The atmosphere was just incredible. Every day there’d be 80,000 or more people packed into the stadium and then in the evening they’d go and another 80,000 would come in,” said Kevin Carroll, MS, CP, vice president of prosthetics for Hanger Prosthetics & Orthotics in Bethesda, MD, who was at the games to offer emotional support to athletes.

During the 11-day games, athletes set 314 Paralympic Games records along with 251 new world records, and Carroll thinks support from the large, cheering crowds was a big factor.

“These young people had come from qualifying events with maybe several hundred or even fewer spectators,” Carroll said. “The energy created by the crowds, the dynamics in that stadium and around the other venues, was simply amazing.”

Prince of sprints

Team USA sprinter David Prince felt that energy as he walked with his teammates onto the track for his event, the T44 400-m race. The 28-year-old Prince, a below-knee unilateral amputee who lives and trains in and around Brandon, FL, had fought hard to be in London. Nine months earlier he’d suffered an injury that his doctor initially told him could keep him out of competition forever.

Last December, just weeks after he’d won gold in the 200 m and 400 m at the 2011 Parapan American Games in Guadalajara, Mexico, Prince went with his wife and six-year-old son to a “jump center,” a huge facility filled with trampolines from which children and adults can literally bounce off the walls.

“I thought I’d get in a pretty good workout jumping around, but about 45 minutes into it I did a cartwheel, didn’t get enough height, and landed on my side with my upper body still flinging up,” he said.

The lack of leverage combined with the uncontrolled energy tore every ligament in the knee above his amputation except his medial collateral ligament; the trauma included a ruptured meniscus and torn anterior cruciate ligament (ACL) and hamstrings.

“I knew when I came down that I’d done something very serious,” he said. “I ripped my pants off, ripped my leg off, and felt around at my proximal fibula and felt that it was only half there. I felt the other half up to my hamstring and a flood of emotions hit me—why did I do this, why did I come here, and I started crying.”

A few days later an orthopedic surgeon told Prince that his was the worst injury he’d seen in 15 years of practice and that, while he might run and jog, he’d probably never again be able to compete at an elite level. Unlike most ACL injuries, the ligament had torn off a piece of bone as it ripped away, partially because of its strength and partially because it was contained within the socket of Prince’s prosthesis.

Prince, who credits his strong Christian faith for helping carry him through this crisis and others, had surgery a few weeks later. He spent as much time as possible in a hyperbaric chamber, even sleeping in it, to promote healing and was able to start walking about seven weeks after the surgery. He then began a six-week course of physical therapy and tentatively began to run, first on an anti-gravity treadmill and then on an indoor track with his therapist. Just three and half weeks after he’d started running he qualified for the Paralympics at the trials in Indianapolis. By the time he got to London two months later he was feeling, “100% plus some.”

In the far outside lane for the T44 400-m final on September 8, Prince focused on the moment and his faith. That faith, along with months of hard work, paid off. Prince won bronze, running the race in 50.61 seconds—a personal best for him and a world record for unilateral below-knee amputees. South African Oscar Pistorius took gold and Team USA athlete Blake Leeper won silver. (The Paralympic T44 classification includes any athlete with a lower limb impairment.)

Prince, a trained prosthetic technician who worked in that role at Hanger, ran in the Ottobock Sprinter carbon-fiber sports foot. He built and aligned the foot himself after his injury, tweaking it so that he would bear more weight on the medial side. In the weeks before the 400-m final, he also had issues with changing volume in his residual limb. By the time he ran that race he’d lost about 1/8″ in volume, dropping him down slightly into the socket and creating a suction cup effect that pulled tissue toward the distal end of his leg. A neuroma in the same location added to his discomfort, which he was able to alleviate somewhat by donning layers of socks to add volume.

Although Prince acts as his own technician at international competitions, not all athletes have the training to adjust and repair their own prostheses and other devices. Luckily for them, lower extremity practitioners also come in force to these games, bringing their skills—and hundreds of pallets of parts and supplies—with them.

In the workshop

Ottobock has run the Paralympic repair facility for more than two decades. For these games the German company brought in 80 technicians to staff the main workshop, smaller repair centers at the Weymouth and Portland Sailing Village and at Egham Rowing and Canoe Sprint Village, and nine competition venues.

Ottobock’s main workshop in the Paralympic Village covered 6500 square feet, including lamination and welding areas, a full machine shop, and a very large area for the 15,000 extra parts and 13.5 tons of equipment Ottobock technical director Ken Hurst knew his technicians would need. Hurst, who makes his home in Manchester in the UK, headed the team of prosthetists, orthotists, wheelchair technicians, and 12 welders who came from 18 countries and spoke dozens of languages—vital skills that would help them communicate with worried athletes experiencing equipment problems needing fast yet precise fixes.

These professionals worked in two shifts to keep the workshop running 16 hours out of every 24, doing up to 200 repairs a day, work that Hurst said included everything from replacing shattered running blades to welding wheelchairs to fabricating entirely new prostheses.

“Swapping out running blades is a big challenge because at that level those athletes are very, very finely tuned—physically, mentally, and on the equipment they use—so getting those blades just how they wanted them was a challenge for the prosthetists involved,” he said. “We also had a lot of people come in with broken down mechanical knee joints, some of which were used in competition and some of which were their daily activity limbs. Some required really major repair work and some we just renewed completely.”

Device diversity

Rachel Neilson, BSC(Hons), a certified prosthetist from Wolverhampton, UK, who normally works with a geriatric population, said these events, her first Paralympics, were, “amazing and emotional.”

“We saw everything, including AFOs, KAFOs, upper and lower extremity prostheses, and wheelchairs of all sorts, as well as custom devices like handbikes and the stools used by athletes to throw the javelin, discus, or shot put,” Neilson said.

The specialized stools, she explained, are utilized mostly by athletes who are wheelchairs users in their day-to-day lives, but some amputees may also need the support they provide.

“Bilateral amputees, for example, may use prostheses normally but would be unable to compete safely using them, so will throw from a platform or stool rather than standing,” she said. “These stools are held in position by tension straps on the field of play to prevent any movement, and there are regulations regarding how much contact between the athlete and their throwing platform must be maintained during competition.”

Neilson said she and the other technicians saw many orthotic devices for repair, mostly belonging to athletes affected by polio who were competing in powerlifting, swimming, or field events.

“I was personally involved in the repair and adjustment of a few conventional metal and leather knee ankle foot orthoses [KAFOs] for the Nigerian team which needed overhauling, including new straps and new footplates,” she said. “But we also had technicians in the workshop who had to weld together side bars that had broken on a few KAFOs and one technician who had to make a new AFO as the client’s current one had snapped across the ankle area.”

Athletes also came in with relatively minor issues, such as wanting the cosmetics of their limb adjusted for an opening or medal ceremony, she said.

“In general, we saw loads of wobbly wheelchair wheels, lots of socket adjustments and alignment issues, as well as some people just wanting advice about whether the orthotic or prosthetic they had was really the best prescription,” she said.

Neilson spent several days working with an athlete from India who came in seeking advice about a leg-length discrepancy.

“It turned out that he had much more complex needs and that his current knee orthosis, which he used to enable him to compete, was not satisfactory and left him with an uncorrected varus foot and ankle and a nearly four centimeter leg-length discrepancy,” she said. “We managed to make him a simple insole that he could wear in his trainers with an increase of two centimeters in height; however, we were unable to do more during the [time we had]. We gave him details for a good orthotist in his own country and told him what we recommended as a prescription for a KAFO with good foot and ankle control.”

Because of the athlete’s serious uncorrected deformities, Neilson advised him to wear his current orthosis full time to protect his joints, but said he was concerned that full-time wear would sap his muscle tone.

“He did admit he walked better and got less tired when using it but he didn’t want to ‘have a weak leg,’” she said.

Neilson said one of the most difficult aspects of the games for her was working with athletes from developing and resource-poor countries who ostensibly came for repairs but really needed and wanted new equipment to replace outdated devices.

“It was difficult—I had people asking me if I could see them privately after the games were over and provide them with a prosthesis, and I had to say there were private clinics but that I myself couldn’t do that. But to see people struggling for what is really clinically appropriate from them was quite hard for me,” she said. “Some people came in with Red Cross-provided limbs that were so basic there was very little I could adjust or do with them.”

More than just technical support

Hurst noted the technicians willingly spent many long hours working intensely and closely with athletes, providing more than just technical support.

“We had a lot of tense athletes and often the time to work on a limb or orthotic device was really quite tight because of the athlete’s schedule,” he said, noting the multinational and multilingual technical team was often able to ease athletes’ anxieties in their own language.

“Just like the athletes, our technicians came from all over the world and the language skills were fantastic,” he said. “Many times we could pair a supporting technician and an athlete from the same country. Cultural differences sometimes make barriers and, though people couldn’t work with those of their own nationality all the time, there was a certain comfort zone for athletes who could at least communicate in their native tongue, which is a great comfort for them when they’re describing the problem.”

Although language wasn’t an issue for an Australian sprinter who fell during a training session, she still needed an emotional boost from the repair team.

“She’d lost her confidence when she fell—it gave her a bit of a scare,” Hurst said. “We took her to the workshop to have her running blades readjusted and then we went out to the warm-up track along with her and her coach and all worked together to psychologically, physiologically, and mechanically put her back together. She got her confidence right and went on to perform her best—she won a gold. These athletes are fantastic but the support they have is fantastic as well.”

One of Neilson’s high points came when she was able to help a Norwegian athlete get back into competition after he broke a blade in training and needed a new one.

“He was devastated because he thought it was really going to hurt his medal chances,” she said. “So I spent a good deal of time with him setting it up and making sure he was happy. There were just five days between me replacing it and his competition day, and he had time for one high-level training session in that time; after that he came back to us and we did some tweaks to bits he wasn’t so happy with.”

The athlete relied on his blade for the run up and push off aspects of the javelin throw, and Neilson had little experience with the sport.

“He was having to tell us how he wanted things, even down to how the spikes on the bottom of his blades were placed—they needed to be just as they’d been on the original blade. We had to pattern that out so we got them on in exactly the right place again. We made an agreement—he said if he won a medal he’d come back and bring me and the other prosthetist a t-shirt.”

Before the javelin thrower’s final competition, Neilson had to leave the games for a family wedding.

“I sat at the wedding with my phone under the table checking the results: he won a bronze medal, and that was amazing,” she said. “I came back to work to find a t-shirt waiting for me on my desk—that was probably the best moment of the games for me.”

Neilson, like other technicians in the workshop, also kept her cell phone handy to take pictures of the many new techniques she was picking up from her colleagues.

“Most of us went home with new ways of doing things—even if it’s really simple it can make things in your day-to-day work a little bit easier for you,” Neilson said.

She picked up a tip on laminating sockets from fellow technicians—turning the object to be laminated upside down to let the air come to the top before the vacuum is turned on.

“It was very different from the way I was taught, but it made sense in terms of being able to expel air so you don’t get bubbles in your laminate,” she said.

Many of the Ottobock technicians were in London for 26 days; all together they made 2074 repairs, Hurst said.

In Team USA’s sports med clinic

Chris Garcia, PT, DPT, SCS, CSCS, did some of his most crucial work before ever leaving the United States Olympic Training Center in Chula Vista, CA, where he works as a US Olympic Committee health services provider.

“I packed my medical kit with everything I thought I would need, and I’m a pack rat,” he said. “I brought everything from electrical stimulations systems to fingernail clippers. You have to prepare for everything. I also brought tons of tape, Ortho Gel, 2nd Skin, and other such products. With prostheses there’s a lot of rubbing and blisters from liners, and managing wound care is a major part of what we do, creating bumpers to off-load injured tissue so that athletes can keep on training through their injuries, for example.”

One of the most common issues at Team USA’s Sports Medicine Clinic, Garcia said, was dealing with the minor illnesses that come with international travel, tension, and 24/7 access to a dining hall serving a seemingly endless array of fabulous food. (Along with the enthusiasm of the crowds and the friendliness of the volunteers, every source LER talked to mentioned the excellence of the meals.)

“Our biggest task was maintaining general health, managing strains and swelling, and just helping the athletes relax and generally keeping them focused and out of environments where they could get injured,” he said.

Garcia’s best moment came when he saw an athlete he’d been working with win a silver medal.

“Elexis Gillette is a totally blind long jumper,” Garcia explained. “We’d been working together for 18 months to perfect his long jump approach and resolve his injuries.”

Gillette’s visual impairment, Garcia said, meant he had trouble staying in a straight line during his long jump approach.

“For three months we worked on proximal hip strengthening and proprioceptive exercise with auditory cues to redirect his spatial awareness,” he said.

The long jumper also faced multiple lower extremity soft tissue injuries throughout the season, Garcia said.

“We addressed those with rehabilitation exercises to correct the underlying impairments that were causing his pain,” he said. “Preparation and prevention is key to working with the elite athlete. Training at such a high intensity and volume for prolonged periods of time, any athlete is bound to sustain injury. However, preventive exercises and proper education can significantly minimize injury rates.”

Ten weeks before the London games, however, Gillette sustained a grade III rectus femoris strain.

“I think that was really tough psychologically for him,” Garcia said. “Going into the games, Lex held the world record in the long jump and his expectations for medalling had been high.”

Garcia treated him with acupuncture, taping, and various manual therapy techniques.

“We progressed running mechanics immediately by unloading his body weight on our weight-assisted treadmill and used explosive drills to maintain lower extremity power, utilizing pneumatic resistance devices without eccentric load to minimize delayed-onset muscle soreness,” he said, noting that after about six weeks, Gillette reported that he felt 99% improved and was ready for the games.

“He was able to win silver, beating a competitor who’d won gold against him in 2004 and 2008,” said Garcia. “He is truly incredible person. I’ve seen him ride bikes. I’ve seen him break wooden boards with his feet. I’ve seen him do tasks that I would have trouble with. He’s learned to adapt and perform under pressure. Seeing all this up close was personally very motivating for me.”