adaptive motor sports rehabilitation program

ABSTRACT


We designed an adaptive motor sports program for community dwelling amputees to
determine its safety and efficacy. Participants were recruited from a community
amputee support group and were asked to respond to a series of questions
pertaining to driving and daily living challenges. The program was a one day
event which consisted of four components: 1) Training on a skills course using
an adapted car focusing on high speed braking using hand controls; 2) Handling
and maneuvering drills using a car with an adapted steering wheel; 3) Driving
simulator with adapted steering wheel and hand controls; and 4) Adapted stock
car racing around a short track with hand controls, adapted steering wheel and a
professional driver in the passenger seat with a steering wheel and speed
controls. Finally, participants completed the Psychological Impact of Assistive
Devices Scale (PIADS) to assess the effects of the program on functional
independence, well-being, and quality of life. All participants reported a
positive impact following the event and PIADS showed highly positive results in
participants' competence, adaptability, and self-esteem scores with the greatest
impact on the adaptability score. This is the first report of the effects of an
adaptive motor sports program on amputees. We showed that using appropriate
safety measures, training and assistive technology, amputees can participate in
adaptive motor sports with profound effects. This provides a unique perspective
to addressing psychological issues, including decreased self-esteem. Further
study is needed to better understand adaptive motor sports in rehabilitation
following amputation.


INTRODUCTION


Suffering an amputation presents multiple problems for an individual, their
family and friends. Psychological issues can be difficult to address and
individuals can feel isolated leading to depression. During Operation Iraqi
Freedom/Operation Enduring Freedom (OIF/OEF), many service members have suffered
traumatic amputation during a time in their life when they were in peak physical
and mental condition. During military service they are embedded in teams and
involved in combat leading to periods of heightened mental awareness. They rely
on this level of stimulation and identify themselves by their unique skill sets
as soldiers. Following traumatic amputation these individuals are transferred to
top-level military hospitals and participate in rehabilitation programs allowing
them to transition to the next phase of their lives. Upon retirement from
military service and transition to their communities, many will lose that
feeling of being part of a team, which can lead to loneliness. In addition, they
may become depressed due to their belief that they can no longer participate in
activities that will stimulate them or that they will enjoy.


Furthermore, amputation does not occur to a particular subset of the population;
rather individuals following amputation can be an extremely diverse group due
varying etiology such as trauma, cancer, infection and vascular problems. Due to
this diverse population the rehabilitation care team needs to gain an
understanding of each patient's potential functional level.


Individuals following amputation at a low functional level often have to relearn
how to perform daily activities with or without a prosthesis, and they tend to
become more dependent on others, leading many amputees to experience decreased
self-esteem1. Others may return to a high functional level. Regardless, the
rehabilitation care team must assess the functional and recreational goals of
the patient to guide the treatment plan with the mission of creating an
environment where there is no limit to what an amputee can accomplish.


Participation in varying activities has a profound effect on an amputee's life.
It has been shown that involvement in adaptive sports increases the quality of
life for persons with disabilities by increasing self-esteem2. Furthermore, it
has been demonstrated that those who participate in these sports have a higher
level of confidence and more motivation to complete daily activities3.


In 2009, the Veteran's Health Administration (VHA) created a national Amputation
System of Care (ASoC) to provide our veterans with high quality, specialized
medical and rehabilitation care to optimize function upon return to home from
service. The ASoC aims to ensure that all veteran amputees receive high quality
rehabilitation care to enable them to accomplish their goals at home, at work
and in the community. Many interventions to prevent depression and loneliness
offered to our veterans through the ASoC include physician visits, medications,
therapeutic modalities (such as physical and occupational therapy), assistive
devices and adaptive equipment, individual and group therapy sessions, peer
support and peer visitation, case management and interactive web-based
information and resources. The ASoC also goes beyond traditional methods to
include recreational activities such as wall climbing, kayaking, golf,
paratriathlon, wheelchair sports and summer and winter competitions through the
VA Adaptive Sports Program.


To our knowledge, an area that has not yet been broached by the ASoC is adaptive
motor sports (e.g. stock car racing). This study assesses the effect of an
adaptive motor sports program on community dwelling amputees to understand how
the assistive technology and rehabilitation engineering used can affect
functional independence, well being, and quality of life. Furthermore, this
study evaluates if the adaptive technology allows participants to more readily
participate in other activities.


METHODS


Participants were recruited from an amputee support group affiliated with an
academic medical center in a large metropolitan area. Eight members of the
amputee support group, ranging in age from 29 to 65 years old, were selected to
participate in the one-day event. Upon arrival at the short track speedway, five
male and three female participants provided surveys with basic demographic
information including driving history and challenges associated with daily
living. Then they signed informed consent documentation and were oriented to two
adapted vehicles that were used for the one day event.


The first vehicle was a standard 4-door sedan with hand control modifications to
be used during training sessions on the street course. The second vehicle was a
stock race car with modifications to allow persons with disabilities to safely
enter/exit and control the car. These modifications include: a removable outer
body panel exposing a door opening in the frame, and a custom designed seat base
that moves fore and aft and swivels out into the door opening for transfer into
the car. Due to the variety of special needs to drive for individuals with
disability there are multiple options for control including: conventional
steering wheel and a left foot gas pedal; manual hand controls (a fold up pedal
blocker plate is used with manual hand controls to prevent inadvertent leg
interference with the pedals); and electric gas and brake controller. All
drivers electrically operate the automatic transmission.
Figure 1: Participant has entered the seat base and used the rotator unit on his
right leg prosthesis to create space to swivel into the car


The steering column is easily modified to adjust for driver's needs. The
steering gear box is modified for easier steering and there is a tandem vacuum
booster master cylinder to make it easier to stop the car. Both the steering and
the brake systems have automatically activating back up systems in case of OEM
failures such as fluid loss, vacuum loss or electrical issues. Lastly, on the
passenger side of the vehicle there is dual steering, brake and gas with switch
controls for turning off the engine and activating the back up systems.


The one day event consisted of training, simulation and racing components:


Training:

*
Led by driver training specialists, participants were instructed in anti-lock
braking systems and introduced to the training vehicle.
*
On the street course, each driver demonstrated competency in high speed braking
using hand controls and performed handling and maneuvering drills using an
adapted steering wheel.



Simulation:

*
Each participant trained using the VXP driving simulator equipped with a MOMO
Force Feedback Racing wheel and iRacing hand controls and software. The iRacing
software offers a wide variety of scenarios preparing the driver both mentally
and physically by teaching and testing reaction time, accident avoidance, hand
eye coordination and many other necessary driving skills.



Racing:

*
Finally, each driver participated in adapted stock car racing around a short
track with hand controls, an adapted steering wheel and accompanied by a
professional race car driver in the passenger seat with a steering wheel and
acceleration and deceleration control.



Following the event, participants were given the Psychological Impact of
Assistive Devices Scale (PIADS) to assess the effects of the adaptive motor
sports program on functional independence, well being, and quality of life.
PIADS is a 26-question survey designed to examine the psychosocial impact of
different assistive technologies. Each question is a word or phrase used to
describe the affect of the assistive technology on the participant's personal
traits and emotions. Participants ranked each question on a scale of -3 to 3. A
negative score indicates a decrease in the particular trait or emotion while a
positive score denotes an increase in the trait or emotion. Each survey was then
scored using the PIADS scoring sheet. Finally, the individual scores were
averaged for each of the three categories.


RESULTS


All participants were able to complete all components of the event. Each person
was able to successfully learn how to use the adaptive technology on the
simulator and effectively apply that to the actual short track experience.
Additionally, all participants reported enjoying the experience and described
feelings of exhilaration, accomplishment and teamwork based on the event. The
PIADS showed highly positive results in participants' competence, adaptability
and self esteem. As table 1 illustrates, the event had a positive impact on
individuals at each level of amputation along all metrics evaluated using PIADS
with the upper extremity level showing the highest scores in all three
categories.


Table 1: PIADS results by level of amputation


Figure 3 reveals a strongly positive response from the event in all three
categories of the PIADS indicating all participants experienced an increased
level of that trait or emotion.


Figure 3: Average PIADS results for all participants by category


DISCUSSION


This is the first description of an adaptive motor sports rehabilitation program
for amputees. This event utilized rehabilitation engineering and assistive
technology to allow persons with disabilities the opportunity to overcome
obstacles and push the limits of their potential. Our experience demonstrates a
safe and effective method of rehabilitation for amputees that can improve their
competence, adaptability and self esteem. Furthermore, the design of this event
using a training program, a driving simulator, and a racetrack experience, is
one that can be duplicated and improved upon.


This experience provides a unique perspective to addressing psychological issues
using rehabilitation engineering and assistive technology for adaptive sports.
It allows the participants to try something new, fun and challenging while in a
safe environment. Our goal is to introduce our amputee patients to programs that
allow them to overcome barriers and return their locus of control.


Further development of adaptive sports is needed to address the goals of our
diverse amputee patient population.


Acknowledgements


The author would like to thank Brian Hanaford, Accessible Racing; Mike Kolar,
Sonalysts Corporation; Charles Hobson, Vanguard Documentaries; Geoffrey Hall,
Rusk Rehabilitation; Terry Eames, Waterford Speedbowl; and Dan Sheppard, Serge
Lentz, Driver Skills Development for their assistance with this event.


References


1.) Burger H & C Marineck (1997). The life style of young persons after lower
limb amputation caused by injury. Prosthetics and Orthotics International,
21(1):35-9.


2.) Valliant PM, Bezzubyk I, Daley L & ME Asu (1985). Psychosocial impact of
sports on disabled athletes. Psychological Reports, 56(1):923-9.


3.) Sporner ML, Fitzgeral S, Dicianno B, Collins D et al. (2009). Psychosocial
impact of participation in the National Veterans Wheelchair Games and Winter
Sports Clinic. Disability and Rehabilitation, 31(5):410-8