SAN ANTONIO — As the winner of a national collegiate wrestling title, a former child wrestler and a bilateral transtibial amputee, Nick Ackerman, CPO, has a unique perspective on the benefits of sports for children with limb deficiencies. Ackerman, a prosthetist based in Des Moines, Iowa, feels passionately about the positive impact sports — particularly wrestling — can have on child amputees.
Ackerman led the prosthetic sports symposium on wrestling with limb deficiencies at the American Orthotic and Prosthetic Association (AOPA) National Assembly. After losing both his legs to meningitis at 18 months, he began wrestling in third grade and was one of the top high school wrestlers in Iowa, before going on to win the 174-pound National Collegiate Athletic Association (NCAA) Division III national title for Simpson College. Ackerman was one of three speakers to share the opportunities the sport of wrestling presents for children with limb deficiency.
“This sport has given me more than I will ever be able to give back to it,” he said. “The lessons learned, the mental toughness and the grit these kids will have will translate to the rest of their lives. And we have the opportunity to expose kids to this.”
A chance to compete
Joining Ackerman in the session was Michael R. Baria, MD, a physiatrist and resident at the Mayo Clinic’s Physical Medicine and Rehabilitation Residency. Baria, a former collegiate wrestler who works with athletes, recently published a study that showed the benefits the sport can have for people with limb deficiencies.
“When we see athletes [with limb deficiencies], the common sports we consider for them are typically track and swimming, sitting volleyball, sled hockey, wheelchair sports, and these are all awesome … but the common theme in each of these is that each of them requires either adaptive equipment or [the athletes] have to compete against a similarly impaired peer,” Baria said. “Wrestling present[s] a unique opportunity in that it let[s] the limb-deficient athlete get integrated right into standard competition without any adaptation or accommodations, and they [do] that against their non-impaired peers.”
Although Baria knew anecdotally of amputees who had succeeded in wrestling and even won titles like Ackerman, he said not much research exists about the safety or effects of the sport on these athletes.
“We wanted to determine two things: One, is wrestling safe for them? And then, was it a positive option?” he said.
Baria and colleagues surveyed 16 wrestlers with limb deficiencies using a questionnaire that collected information on demographics, limb loss etiology, achievements, quality of life, barriers to entry, residual limb complications and musculoskeletal problems. All survey participants were at least 5 years old, had a minimum of 1 year wrestling experience and had limb deficiencies at or proximal to the transtibial/transradial level. The researchers used descriptive statistics for a general analysis and Fisher’s exact test to examine the risk factors for residual limb complications.
Respondents were all male; nine had congenital amputations and seven had acquired amputations. The median age of acquired amputation was 6 years. Four acquired amputations were traumatic and three were infectious. Nine respondents had transtibial amputations, five had transfemoral amputations and three had transradial amputations.
To determine the safety of the sport, Baria and colleagues measured the rates of injuries and complications. The results showed a 50% residual limb complication rate. Complications included skin breakdown (six), residual limb pain (five), swelling (two), phantom pain (two) and infection (one). Significant musculoskeletal injuries, defined as “any injur[ies] that withheld the athlete from competition,” were reported by 37.5% (six) of patients. These injuries occurred in the shoulder (two), elbow (one), lower back (three) and knee (three).
Due to the 50% complication rate, Baria said, “if we are going to recommend an individual be more active in the sport, it definitely warrants education and some kind of monitoring of the athlete as well as parents and coaching staff, and then just making meticulous skin care a priority.”
He noted the injury rate does not appear to be higher than for nonimpaired wrestlers, but more research is needed for an exact comparison.
Among the 16 respondents, two were NCAA champions, two were NCAA tournament qualifiers and seven were collegiate wrestlers. All respondents reported the positive effect wrestling had on their lives.
“Everybody in the study said wrestling had a positive impact on their overall quality of life,” Baria said, adding, “Ninety-five percent said it had a positive impact on their physical health. Eighty-seven percent said they did not have any difficulty finding acceptance from their teammates, their coaches or their competitors.”
More than half (56%) of respondents reported using a prosthesis for cardiovascular and/or strength training, but no respondents used a prosthesis for wrestling training or competition. One respondent used modified grips for strength training. No other adaptive equipment was reported. Baria said this is unique among sports for amputees.
“Limb deficient wrestlers can and do succeed against their nonimpaired peers, and they do this without the need for any accommodations or adaptations. To my knowledge, there is no other sport that boasts this degree of competitive equality between impaired and nonimpaired competitors,” he said.
Baria said wrestling’s weight class system provides a unique opportunity for limb deficient athletes; a wrestler who is missing a limb tends to have a larger torso than his nonimpaired competitors because they are the same weight. At the same time, he said, size does not provide an unfair advantage for impaired athletes.
“Strength is one piece of wrestling, but the stronger wrestler is not always the better wrestler,” he said. “There are many other facets to the sport, so there might be a relative advantage but it is not an absolute advantage.”
“Additionally, there are going to be a whole host of techniques that are unavailable to these athletes” – for example, lower limb amputees cannot push off from a leg or trip their competitor, he said.
Baria and colleagues concluded wrestling is a healthy and positive option for nonimpaired athletes. It also involves low barriers to entry: Baria said there is no financial investment, no special equipment and no complicated training needed.
“The majority of the wrestling community knows about these stories [of successful impaired wrestlers] and I think they are going to be willing to open their doors and their training facilities to these athletes,” he said.
Baria acknowledged the limitations of the study, including selection bias (those who volunteered to take the survey were more likely to have had positive experiences), a small sample size and lack of female participants. He said further research should focus on a more detailed assessment of injuries; prospective study of mental and physical health outcomes; and preventive strategies for residual limb complications.
Tips for practitioners
Athletes with limb deficiencies, including wrestlers, need specialized care. John Fergason, L/CPO, chief prosthetist at the Center for the Intrepid at San Antonio Medical Center, said he is always looking for new “tools” to add to his prosthetic “toolbox” for patients who are also athletes. Prosthestists should ask their athletes, “What are you motivated to do and how can I help you get there?” Fergason said.
Fergason has worked with athletes for about 10 years and said they need assistance not only in preparing for their sport but also in their off the mat, off-season cardiovascular training. One of the most important components of this training is flexibility. Athletes want to improve their range of motion.
“We need flexion. Everyone wants to do squats,” he said. “I use a lot of breakaway brims.”
Fergason also works with subischial transfemoral sockets for athletes, and said he is investigating the usefulness of adjustable sockets.
Performance can be limited by factors, including stability, training, energy consumption and comorbidities, according to Fergason.
One important element to consider is the limb socket interface, which is “one of the big things that is going to limit people’s ability to perform in their cardiovascular activities,” Fergason said. “You have to look at socket design.”
Practitioners should consider weight tolerance when designing the socket.
“We have to talk about how we are going to design the sockets to maximize the good weight-bearing areas and protect and minimize weight-bearing in at-risk areas,” he said.
Fergason measures weight-bearing tolerance through repetitious cyclical loading.
Practitioners should consider limb socket dynamics and limb socket interface, weighing stability against comfort, he said.
For athletes who need a prosthetic foot to perform, Fergason said utility feet are an important option.
“We need to be using feet that you can walk on comfortably and that you can [accelerate] into a full spring,” he said. “People cannot afford five feet, so I am personally looking for a utility foot that I can have a whole range of activity on – someone can walk, jog and run.”
Complications of the residual limb are common for athletes, and Fergason offered the following tips:
- For sweat, use non-prescription antiperspirants or foot powder.
- For skin abrasions, use lubrication and do not ignore the abrasion. It can turn into an epidermoid cyst.
- For contact dermatitis from allergens or irritants, remove the offending agent and use topical creams, cortisol steroids and cool compresses.
Fergason said he always advises his athletes to overhydrate to prevent volume change.
“Be creative,” he said. “Accommodate with what you have available as best you can. Adjust as they progress.”
Child athletes and parents
Ackerman said practitioners should keep in mind working with a child athlete is just like working with any other patient who has specific needs.
“Everything is custom,” he said. “You do not have two patients who have the same socket and we do not have that option for wrestling either.”
Practitioners working with wrestlers should keep skin complications in mind – skin protectors can help, Ackerman said – and work to create a device that can provide protection and traction, if needed. Many wrestlers with limb deficiencies do not wear any protective device, but weight-bearing can become difficult for some as they get older. Weight changes can also create different needs.
For traction, leather lacers can help. Ackerman has designed one for an amputee from a wrestling shoe. Practitioners should keep in mind the athlete’s needs on the mat, because a bulky device will probably not help.
“The last thing I wanted on my leg [as a wrestler] was something that was bigger than my leg,” he said.
Another important element of care for young wrestlers with limb deficiencies is the relationship between parent and prosthetist.
“The correct prosthetist, patient and parent[s] are keys to this success,” he said.
Ackerman said communicating with parents is key to help them understand the opportunities wrestling can provide for a child with limb deficiencies. He said his parents’ refusal to treat him like he was “different” helped him succeed in the sport.
“We have to convince the parents. The parents are the linchpin in this whole process,” he said. “We have to tell them that this is good for their son or daughter.”
Ackerman, who has children, acknowledged parents may need more information or assurance.
“Wrestling from the outside looking in can be seen as brutal. [Your] child appears to be outmatched. Growing up, I lost a lot. I would get beat often,” he said. “As a parent, we want to protect our kids. [And] then you [as a practitioner] are sitting in the room with a parent of a kid who has gone through a lot physically and the instinct for the parent is to protect. But I think what is more damaging is being pulled from it.”
He added, “The sport of wrestling instills a certain amount of grit, a certain amount of work ethic and a certain amount of confidence that is unlike any other sport in my opinion.” – by Amanda Alexander
- Ackerman N, et al. Paper C. Presented at: American Orthotic and Prosthetic Association National Assembly; Oct. 7-10, 2015; San Antonio.
- Baria M. Am J Phys Med Rehabil. 2015;doi: 10.1097/PHM.0000000000000295.
Disclosures: Baria reports Archbishop Moeller High School provided funding for participant remuneration for the study. Ackerman and Fergason report no relevant financial disclosures.