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Athletic Assistive Technology for Persons with

Physical Conditions Affecting Mobility


David Hill, BS, MS, Donna Moxley Scarborough, BS, MS, PT, Eric Berkson, BA, MA, MD, Hugh Herr, BA, MS, PhD

ABSTRACT
Recent advances in technology have allowed athletes with physical conditions to perform at increasingly high levels. After
the ruling that one such athlete had an advantage over able-bodied athletes before the 2008 Olympics, many question
whether these technological advances have even augmented athletic abilities. Although much progress has been achieved,
technology for disabled athletes must be far advanced to allow them to reach and surpass the ability level of able-bodied
athletes. Here, we review the current state of assistive devices created to assist athletes with physical conditions affecting their
mobility. We form a quantitative comparison between athletes with and without physical conditions, lay out recent ad-
vancements in the development of sports-related assistive devices, and discuss the implications of these devices. Using the
Paralympics as a guide, this work serves as an overview of the current state of assistive technology for athletes with mobility
conditions and a tool for future researchers attempting to bridge the gap between athletes with and without physical
conditions. (J Prosthet Orthot. 2014;26:154Y165.)
KEY INDEXING TERMS: assistive technology, prosthesis, wheelchair, sports, Paralympics, athletes with physical conditions,
athletes with mobility conditions, disability

I
n 2008, the International Association of Athletics Federa- developments, which could contribute to a future wave of aug-
tions (IAAF) began a worldwide debate when they established mentative devices.
Rule 144.2(e), prohibiting the use of technical devices that
offer a competitive advantage.1 Specifically citing springs as ad-
CONTRIBUTION
vantageous, this rule resulted in the immediate disqualification
of Oscar Pistorius, the South African bilateral amputee sprinter Disability is an umbrella term often used to describe a
vying to become the first amputee to compete with able-bodied physical or mental impairment that substantially limits one or
runners at the highest level. Extensive trials and investigation more major life activities and causes participation restrictions
resulting from this ruling caused its eventual repeal,2,3 allow- for an individual.4 However, using any form of this term to
ing Oscar Pistorius to make history as the first-ever amputee refer to humans is unacceptable because the ability to perform
sprinter to compete in the Olympics. The initial verdict evoked at extraordinary levels can be restored given the right tech-
some pivotal research in sports performance enhancement for nology, as evidenced by Oscar Pistorius. The focus of this work
athletes with mobility conditions (AMCs), and a rather inter- is athletes with physical conditions, specifically conditions that
esting question emerged: affect limb and motor function. We discuss current work on
Just how far can assistive technology enhancements take technology that assists these athletes, thus directly address-
all athletes in the future? ing activity and participation restrictions and improving the
To examine this question, in this article, we explore the cur- athletes ability to perform. The goal is to outline current de-
rent state of para-athletics, surveying the literature to assess the sign approaches, evaluating their efficacy and potential for
present achievements of AMCs, and find recent advances in as- future applications.
sistive technology for sports-related applications. This explora-
tion provides insight into the current direction of assistive device PREVIOUS WORK
Sports for AMCs have made great strides since the inception
of the Paralympics approximately a half century ago.5 Within
DAVID HILL, BS, MS, and HUGH HERR, BA, MS, PhD, are affiliated the last 2 decades, the Paralympics and the Olympics became
with the Biomechatronics Group, Media Lab, Massachusetts Institute more closely tied, resulting in a sudden surge in exposure and
of Technology, Cambridge, Massachusetts. popularity, as well as newfound disabled star athletes. Since
DONNA MOXLEY SCARBOROUGH, BS, MS, PT, and ERIC BERKSON, then, much work has gone into studying sports performance
BA, MA, MD, are affiliated with the Mass General Sports Performance of AMCs from a variety of angles. Although many focus on
Center, Department of Orthopaedic Surgery, Mass General Hospital, the Paralympics and its history,5Y7 others cover topics rang-
Boston, Massachusetts. ing from psychological characteristics of para-athletes to so-
Disclosure: The authors declare no conflict of interest. ciopolitical implications of para-athletics.
Copyright * 2014 American Academy of Orthotists and Prosthetists One of the major concerns in all sports is injury. Medical
Correspondence to: David Hill, BS, MS, Biomechatronics Group, professionals and athletes alike are deeply invested in study-
Media Lab, Massachusetts Institute of Technology, 75 Amherst St ing the occurrences, causes, prevention, and diagnosis of in-
E14-348U, Cambridge, MA 02139; email: dhill24@mit.edu juries. In 2009, Miller8 investigated medical issues associated

154 Volume 26 & Number 3 & 2014

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Journal of Prosthetics and Orthotics Athletic Assistive Technology

with Paralympians, discussing common injuries and illnesses worldwide sports competition for athletes with conditions that
encountered by these athletes. Mason9 furthered this discus- affect athletic ability. It officially began in 1960. Now, it occurs
sion in 2012 when he reviewed the history of sports medicine immediately after the Olympics every 4 years and in the same
for AMCs, forming one of the most comprehensive assessments city.31 Examining Paralympic events gives clues to which as-
of AMC sports medicine to date. Others have examined specific sistive technologies are most advanced and useful for athletic
occurrences of injury to uncover where and how AMCs are most activities. Further, comparing the top performances in the Para-
vulnerable.10Y14 lympics and the Olympics gives a more quantitative measure
Psychological factors affecting AMC sports performance have of the efficacy of these technologies in matching biological
been studied extensively as well. Evaluations of self-esteem, hap- performance.
piness, and other psychological factors arose as early as the 1980s, The Paralympics features 26 distinct events, ranging from
showing that there are mental benefits of sports participation for aquatics to wheelchair tennis. Of these, 23 coincide with Olym-
persons with physical conditions.15 More recently, Martin16 found pic events (see Table 1). Observing the absence of certain Olympic
that sport experience positively affected motivation for youth with sports in the Paralympics offers some obvious key distinctions.
physical conditions. Other reviews by Jefferies et al.,17 Deans Specifically, more dynamic sports with varied movements seem
et al.,18 and Martin19 emphasize the growing importance of to be the most difficult to reproduce, especially combat sports.
sports psychology for AMCs. As a result, new methodologies for Even those represented in the Paralympics can be achieved only
providing sufficient psychological assessments to AMCs by sports through the use of wheelchairs. Perhaps, this underscores the
psychologists have arisen.20 present shortcomings in prosthetic devices, which tend to be
Social and political issues are the focus of an overwhelm- most powerful for single-plane movements.
ing majority of publications concerning athletes with physical Further disparities can be seen in the world records posted
conditions. Often, these are related to civil rights, accessibility, in the two competitions. The IPC tracks records only in four
and unfair treatment. One such example is the disparity in me- sports: athletics, powerlifting, shooting, and swimming.31
dia coverage for para-athletes when compared with able-bodied
athletes. Traditional media sources have failed to give equal
coverage to AMCs, and when they do, the language used has Table 1. Basic Olympic and Paralympic events lists
commonly been perceived as negative and offensive.21,22 Fur-
ther, some have criticized the disempowerment of para-athletes Olympics
underlying the structure of competition. A clear separation from and
the Olympics, substantial funding differences, and disparate media Olympics Paralympics Paralympics
coverage make the Paralympics, and equivalently AMC sports, less Badminton Aquatics Boccia
inclusive than it is often stated and intended to be.22Y27 Bobsleigh Archery Goalball
To our knowledge, few academic publications have reviewed Boxing Athletics Wheelchair dance*
assistive technology for AMCs. Burkett28 recently conducted Golf Basketball*
two such reviews, one examining technology used exclusively Gymnastics Biathlon
in summer Paralympic competitions and a secondary piece fo- Handball Canoe/kayak
cusing on technology for the winter Paralympics.29 In addition, Hockey Curling*
Luge Cycling
Magdalinski30 briefly discussed assistive sports technology in a
Modern pentathalon Equestrian
2012 review of prostheses and artificial skins. Previous studies
Skating Fencing*
of assistive devices for sports mostly focus on prostheses or ex- Taekwondo Football
clusively Paralympic technology. Here, we review the current Wrestling Ice hockey
state of para-sports performance and many devices built to aid Judo
athletes with mobility conditions, using the Paralympics as a Rowing
starting point and method for evaluating the impact of assistive Rugby*
technology. Sailing
Shooting
Skiing
PARA-ATHLETE PERFORMANCE Table tennis
Tennis*
One way to evaluate the current state of para-sports per-
Triathlon
formance is to assess the Paralympic Games, analyzing its
Volleyball
history and comparing it with the Olympics. Although Inter- Weightlifting
national Paralympic Committee (IPC) regulations, which have
the potential to limit improvements in athletic performance, pro- The first column displays competitions that are performed only in the
hibit the use of certain assistive devices, this analysis does Olympics. The second column shows events that are performed in both
offer some indirect insight into the state of assistive sports the Paralympics and the Olympics. The third column shows events that
are performed in the Paralympics but not in the Olympics. *Wheelchair-
technology and its ability to facilitate world-class athletic only events in the Paralympics.
achievement. The Paralympics is the Olympic-equivalent

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Hill et al. Journal of Prosthetics and Orthotics

Table 2 lists select aquatics and athletics records and compares (see above), one can notice that each of these high-performing
para-athlete records with equivalent Olympic athlete records. para-athletes competes using a wheelchair. This gives rise to
In the Paralympics, competitors are classified on the basis of two key observations about para-sport and the assistive de-
ability level and/or condition type. Broadly speaking, the IPC vices that facilitate them: 1) wheelchairs are currently the
recognizes six condition categories: amputee, cerebral palsy, most effective and versatile assistive devices and 2) all as-
intellectual, wheelchair, visual, and les autres.31 Classifications sistive devices fall short of consistently reproducing natural
differ in every sport and follow a set of guidelines established athletic ability.
and maintained by the IPC. Examples are shown in Table 2 and
are defined as follows: DESIGN APPROACHES
Aquatics Designs of assistive devices for athletic activities depend
(numbers move from least ability to most ability) mostly on the sport, with each differing in the desired tasks and
1 to 10: Physical goals. With this in mind, the following review of assistive device
11 to 13: Visual design approaches is organized according to the general task
14: Intellectual and/or sport. The section is split into five major subsections:
wheeled mobility, ambulatory mobility, nonwheeled seated sport,
Athletics snow and ice mobility, and aquatic mobility. Wheeled mobility
11 to 13: Blind/visual covers advances in manual wheelchairs, cycling, and powered
20: Intellectual wheelchairs. Ambulatory mobility includes recent developments
32 to 38: Cerebral palsy (32Y34 wheelchairs, 35Y38 ambulant) in running and jumping devices for athletes with lower-limb
40 to 46: Amputation or other condition such as dwarfism conditions. The nonwheeled seated sport subsection discusses
(ambulant) commonly used devices for seated track-and-field sports as well
51 to 58: Spinal cord injury or amputation (wheelchair) as fishing. Snow and ice mobility covers skiing and snow-
boarding technology. Finally, aquatic mobility discusses assis-
tive technology for swimming and rowing.
Apparent differences exist within the classes of para-athletes
and between athletes with and without physical conditions. WHEELED MOBILITY
These are highlighted by record comparisons (see Table 2). Manual wheelchairs are the most widely used assistive de-
Quickly, one can see which conditions affect performance most vices for athletes with ambulatory conditions by a substantial
severely. In particular, athletes with intellectual conditions seem margin. Sports conducted with them include tennis, rugby, cur-
to be affected the most, with world records reported only for six ling, and dance, to name a few. When compared with other
athletic and aquatic events. No other condition affected athletic devices, they tend to be more versatile and effective. Their wide-
performance as drastically as intellectual conditions; however, spread use has led to a number of dedicated publications.32Y36
ability level is directly linked to the degree and type of condition Years of work have gone into creating ergonomic wheel-
and differs for every sport. chair designs.32 To accomplish this, wheelchairs are tweaked
Aquatic records follow in an order most would expect. In to be lighter, faster, and more maneuverable. Advances in ma-
all cases, para-athletes post slower records than Olympic ath- terials and mechanisms have made this possible. Typical wheel-
letes. Differences in these records tend to increase with race chairs consist of several customizable components, including
distance. For example, in short 50-m races, high-level para- the frame, seat, and wheels. Each one affects performance. Light
athletes fall short of Olympic athlete record times by just frames are essential for acceleration and upper-limb preserva-
greater than 2 seconds (10%), showing that these athletes per- tion, seat cushions provide pressure relief for sustained use, hand
form at an elite level despite the condition. However, as races rims govern control and propulsion tasks, and casters and
become longer, the disadvantages of para-athletes begin to straps provide stability.36Y38 Further, wheel orientation/camber
show more. Eventually, record time spreads increase to nearly (Figure 1A) has been shown to affect maneuverability,34,36,41
2 minutes (13%). and seat orientation (Figure 1A) influences stability and con-
On the other hand, athletics records are more interest- trol.34,36 Decisions regarding these parameters differ on the ba-
ing. Although they mostly follow the trends seen in aquatics sis of sport.
competition, there are a few unexpected observations. As one Component tweaks, as described above, account for most
would anticipate, athletes without conditions typically outper- sport wheelchair design decisions. Although the decisions to
form para-athletes, especially in jumping and throwing events. be made remain the same, the methods for determining them
However, a trend begins to arise in longer races (i.e., 800, 1,500, differ, with some even developing novel devices and experi-
5,000, and 10,000 m). In these races, some para-athletes have ments to decide.42 Others have explored dedicated designs for
exceeded Olympic athlete times. The most drastic example of specific communities.43Y45 Berger et al.43 designed a wheel-
this occurs in the 10,000-m race, when the fastest para-athlete chair for basketball players in the Netherlands with a rede-
outperformed his Olympic athlete counterpart by greater signed frame to reduce weight and increase strength and an
than 6 minutes (25%). Although this seems counterintuitive altered wheel position, angled in such a way that tire defor-
at first glance, upon reviewing the Paralympic classifications mation is eliminated without sacrificing maneuverability.

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Journal of Prosthetics and Orthotics Athletic Assistive Technology

Table 2. Mens aquatics and athletics world records

World records (men)


Aquatics
Paralympics
Event S1YS10 S11YS13 S14 Olympics
50-m Freestyle 0:23.16 0:22.99 0:20.91
100-m Freestyle 0:50.87 0:50.91 0:46.91
200-m Freestyle 1:54.46 1:56.78 1:58.42 1:42.00
400-m Freestyle 4:04.20 3:58.78 3:40.07
1500-m Freestyle 16:24.63 16:33.79 14:34.14
50-m Backstroke 0:28.42 0:27.57 0:24.04
100-m Backstroke 1:00.01 0:56.97 1:01.85 0:51.94
200-m Backstroke 2:15.04 2:18.10 1:51.92
50-m Breaststroke 0:29.16 0:29.90 0:26.67
100-m Breaststroke 1:04.02 1:03.91 1:06.69 0:58.58
200-m Breaststroke 2:24.23 2:33.82 2:07.01
50-m Butterfly 0:25.25 0:24.53 0:22.43
100-m Butterfly 0:55.99 0:54.92 0:49.82
200-m Butterfly 2:13.78 2:13.40 1:51.51
Athletics
Paralympics
Event 11Y13 20 32Y38 40Y46 51Y58 Olympics
100 m 0:10.46 0:10.79 0:10.72 0:13.63 0:09.58
200 m 0:21.05 0:21.82 0:21.30 0:24.18 0:19.19
400 m 0:47.88 0:49.33 0:45.39 0:45.07 0:43.18
800 m 1:52.13 1:43.55 1:51.82 1:31.12 1:41.01
1,500 m 3:48.31 3:54.07 3:30.12 3:50.15 2:54.51 3:26.00
5,000 m 13:53.76 12:33.72 14:20.88 9:53.05 12:37.35
10,000 m 30:24.88 38:12.96 30:15.35 19:50.64 26:17.53
4  100 m 0:42.46 0:44.81 0:41.78 0:49.89 0:37.04
4  400 m 3:27.89 3:38.92 3:27.00 3:05.46 2:54.29
High jump 2.03 2.12 2.45 m
Long jump 7.66 7.48 6.48 7.58 8.95 m
Triple jump 16.23 15.20 18.29 m
Shot put 16.62 16.29 17.52 18.38 16.37 23.12 m
Discus throw 53.61 55.81 63.46 60.72 74.08 m
Javelin 64.38 57.81 62.15 50.98 98.48 m

IPC.31
The far left column displays events. The middle columns display world records set by para-athletes. They are split on the basis of classification. For aquatics,
lower numbers generally indicate less ability, whereas higher numbers indicate more ability. The columns are split on the basis of three separate classifications:
physical conditions (1Y10), visual conditions (11Y13), and intellectual conditions (14). Athletics competitors are split into five classes: blind/visual conditions
(11Y13); intellectual conditions (20); cerebral palsy (32Y38), wheelchair (32Y34) and ambulant (35Y38); amputation or other conditions such as dwarfism,
ambulant (40Y46); and spinal cord injury or amputation, wheelchair (51Y58). The far right column displays world records set by athletes eligible for the
Olympics.

Advanced wheelchairs are often quite expensive, limiting their offer distinct advantages and disadvantages, which depend on
use to more wealthy countries and individuals. To combat this, the activity and the condition of the user. Tandem bikes are
Authier et al.45 developed a low-cost sport wheelchair for de- made for two riders. There are two seats and two sets of han-
veloping nations. Wheelchair development and selection both dlebars. Athletes with visual conditions use these; the athlete
require a specialized and customizable approach based on body sits at the back and a sighted pilot guides from the front. Ath-
type, activity, and even location. letes with balance deficiencies use tricycles. The extra wheel
Para-cyclists have a choice of four different types of cycles: eases balance, allowing athletes to stabilize in a way that they
tandem cycles, tricycles, bicycles, and hand cycles. They all cannot on two wheels. Athletes with mobility conditions use

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Hill et al. Journal of Prosthetics and Orthotics

Figure 1. Manual wheelchair, hand cycle, and paramobile device. A, Wheel camber is the orientation of the wheel relative to the frame (left
column). Positive camber (bottom left) creates a larger base of support and improves lateral stability, hand-rim comfort, and maneuverability.
However, positive camber also increases rolling resistance, decreases seat height, and enlarges footprint/turning radius. Seat angle is the ori-
entation of the seat relative to level ground (right column). Seat dump (bottom right) improves lateral stability and hand-rim accessibility, but it
decreases rearward stability and height. Both wheel camber and seat angle should be chosen appropriately to optimize individual performance,
balancing their positive attributes with the negative.36 B, A hand cycle with an adjustable chassis allows the rider to adapt to off-road conditions.39
C, A paramobile device for paraplegics facilitates upright posture useful for golfing.40 Adapted from Goosey-Tolfrey36 (A), Siebert39 (B), and
Wucherpfennig and Boyer40 (C).

standard bicycles, if possible. These follow the standard design, that shorter crank lengths tend to be more efficient. Further,
but slight modifications are sometimes made to meet the needs Kramer et al.47,48 analyzed the effects of crank angle and width
of the condition. Many of these modifications involve custom on performance in two separate articles, revealing that a more
attachments between the rider and the bike. Finally, hand cycles pronated handle offers improvements, whereas width has min-
are operated by hand instead of foot. Usually, the rider assumes imal influence. Arnet et al.49 found that an upright backrest
a kneeling or lying position.31 We focus only on hand cycles with a distant crank position reduces shoulder load. Finally,
because either the others are beyond the scope of this article or van der Woude et al.34 measured the effects of gear ratio and
limited innovation exists specifically for AMCs. mode on propulsion characteristics and observed a significant
Hand cycles share many of the same design goals as wheel- reduction in metabolic expenditure during synchronic arm use
chairs. Like wheelchairs, hand cycles have progressed with ma- with lighter gear ratios. Hand cranks are a key component of
terials and designs. Further, custom component layouts are used hand cycles, and, as such, their development over the years has
to optimize individual performance. This versatility can be seen led to enhanced ability.
in Sieberts39 work on an adjustable chassis for a mountain hand Powered assistive sports devices are extremely uncommon.
bike. As shown in Figure 1B, Siebert alters the tire layout and This makes sense for competitive sports, but for recreational
builds completely adjustable cranks, footrests, backrests, brack- sports, these are needed to promote activity among popula-
ets, and drive trains to allow total customizability in off-road tions with the most serious conditions. So far, the most com-
conditions. mon powered devices used for sport are paramobile devices,
Hand cranks are unique to hand cycles and a major source those that mobilize paraplegics. These often assist in sitting-
of customization. Many have studied the performance differ- to-standing transitions, and although this may sound minor,
ences caused by altering them.46Y51 These studies typically re- it allows paraplegics to take part in less rigorous standing
volve around mechanical efficiency and power effects. Crank activities, such as golf.40,52 Figure 1C displays this transition.
length was studied by Goosey-Tolfrey et al.,46 who determined The most common commercial paramobile devices resemble

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Journal of Prosthetics and Orthotics Athletic Assistive Technology

Perks52 upright wheelchair and use a motorized, tiltable appearance.59 Running prostheses, such as the ones shown in
seat that erects the rider in a manner suitable for swinging a Figure 2, are made to mimic the spring-like behavior of the
golf club. human ankle complex, specifically the Achilles tendon,3 but
their form factor is often made to resemble that of a quadru-
AMBULATORY MOBILITY pedal animal.60 Using this cheetah architecture, lower-limb
With Oscar Pistorius success in the 2012 Olympics came amputees have been able to achieve new athletic heights,3,61,62
much coverage of lower-limb prostheses, both as praise and inching closer to Olympic levels (see Table 2).
criticism.53Y58 Some argue that state-of-the-art lower-limb pros- In addition, alignment and residual limb to prosthesis at-
theses offer amputee athletes distinct advantages when com- tachment continue to be problems for amputee athletes. No
pared with their able-bodied counterparts.56,57 These sentiments matter how advanced prostheses become, they are useless with-
do make a statement about the progress that ambulatory pros- out suitable means to attach and align them. To address the first
theses have encountered in recent years; however, they over- issue, Burkett et al.63 studied alignment for transfemoral am-
look the progress that remains to be made. This potential for putee runners, showing that lowering the knee joint improves
future development is highlighted by the large amounts of running velocity and symmetry. New, more intimately attach-
work still being conducted to further develop running prosthe- ing sockets have been produced to address the second issue.
ses. Table 1 shows that wheelchairs are still a very common tool Madigan and Fillauer64 designed the 3-S Socket, a silicon suc-
for athletes with ambulatory difficulties. Future developments in tion socket made for both the upper and lower limbs. Further,
ambulatory prostheses for athletes seek to open up opportunities Tingleff and Jensen65 made an adjustable socket from carbon
for nonwheelchair athletes that are currently unavailable. Here, and polyaramid fibers that uses a slit to form a flexible flap for
we discuss recent developments. readjustment. This socket is made to offer versatility for multi-
Passive running prostheses have progressed with materials. ple sports, which require different socket fits. In all cases, the
Because modern advances in materials have caused them to alignment and socket adjustments were made to optimize ath-
become lighter but stronger, prostheses using these materi- letic performance and fit.
als can withstand a higher load demand while not inhibiting Presently uncommon, powered running prostheses should
the wearer because of weight. In addition, recent innovation become more common in the future. As of now, there is
has seen these devices become more biomimetic, but not in limited published work. However, Huff et al.66 developed a

Figure 2. Passive lower-limb prostheses. A, Flex-Foot (Flex-Walk, Laguna Hills, CA, USA) (Modular III). B, Flex-Sprint I (Ossur, Reykjavik,
Iceland). C, Flex-Sprint II (Ossur). D, Flex-Sprint III (Cheetah; Ossur). E, Flex-Run (Ossur). F, Symes-Sprint (Ossur). B to F, Specialized running
prostheses. Adapted from Lechler and Lilja.59

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Hill et al. Journal of Prosthetics and Orthotics

running controller for a powered knee-ankle prosthesis capa-


ble of reproducing some key elements of healthy running.
These sorts of devices are far from commercial use, but
they will likely be the next wave of assistive devices for am-
putee athletes.
Jumping requires similar assistance as running for ampu-
tees. Spring-like propulsion is key. Many have studied the ef-
fects of common jumping/running prostheses on performance,
comparing amputee jumpers with individuals with biological
limbs.67Y74 These studies have shown that amputees often re-
plicate the techniques of biological limb jumpers but exhibit
certain compensatory mechanisms and asymmetries that lead
to reduced ability.

NONWHEELED SEATED SPORT


Seated sports are quite popular for AMCs. These activities
are conducted either using no technology, such as seated vol-
leyball, or using adaptive chairs, such as several Paralympic
tossing events. Although nonwheeled seated technology sub-
stantially limits mobility, it does offer stability that is difficult
to achieve with wheeled devices. This is essential for sports that
require the athlete to form a stable base and toss an object, for
example, shot put, discus throw, and javelin.
As previously mentioned, some track-and-field competitions Figure 3. Adapted fishing rod. The rod comprises a base for stability
require seated technology. Specifically, the throwing sports re- and a motored reel for increased power. The fishing rod is rotatable and
quire adaptive seats called throwing frames. Limited academic adjustable to aid those with mobility conditions. Adapted from Byrd.84
research has been conducted on these devices, but some have
made attempts at analyzing them to determine advantageous
configurations for competition and classification.75,76 However, Prostheses for snowboarding are similar to those for skiing.
neither of these studies provides conclusive evidence to im- Versatile leg movement is key. Joint rotation, in all planes, is
prove athlete performance. Others have developed more adjust- essential. Minnoye and Plettenburg92 developed a transtibial
able throwing frames,77 which are hoped to enhance training snowboarding prosthesis capable of passive inversion/eversion
and performance. and plantarflexion/dorsiflexion to make amputee snowboard-
Fishing is another example of a seated sport that requires ing more comparable with snowboarding with biological
technology manipulations. This has been a significant point of limbs. Similarly, St-Jean and Goyette93 developed a passive
innovation, particularly among independent inventors. Mecha- multi-axis springed ankle prosthesis for ice skating to im-
nisms have been developed to assist in holding the fishing prove mobility for a 7-year-old figure skater. Robust multi-axis
rod,78Y80 casting,81,82 and reeling.83 Examples of these modifi- joint prostheses are difficult to build, but they are critical for
cations are shown in Figure 3. For chair users and those with athletic performance, especially activities that involve snow or
upper-limb deficiencies, rod stability, power, and control are ice mobility.
critical issues. More recent advances continue to tackle these
problems.84 AQUATIC MOBILITY
Competitive swimming is commonly performed without
SNOW AND ICE MOBILITY assistance. One example is the S3 classification, commissioned
Snow and ice activities are extremely popular among AMCs. by the IPC, which allows athletes with amputations of all
For decades, adaptive equipment has been created to account four limbs to compete against one another.31 However, there
for these conditions. These adaptations include outriggers/ does exist technology designed specifically to assist AMCs
ski-tipped crutches to stabilize, stirrups for leg support, adap- in swimming.
tive cuffs for persons with upper-arm conditions, modified boots Swimming prostheses (see Figure 5) typically take the form
and ski attachments for maneuverability, and sit skis with kayak- of fin-like attachments, and many are designed to simplify
style poles for athletes with more severe conditions.85,86 Skiing navigating the poolside.94 Some have attempted to improve
prostheses typically focus on facilitating knee and ankle move- upon these by making more versatile feet. Colombo et al.95 built
ment while establishing stability.87Y89 Sit skis (Figure 4), on the a leg capable of both walking and swimming. The approach
other hand, are designed to maintain center of mass stability described was an adaptable pylon ankle prosthesis capable of
and inertia, often using adjustable frames.90,91 These adjust- being manipulated into a fin-like configuration. Figure 5B
ments influence both stability and comfort.90 shows this adaptation. Yoneyama et al.,96 on the other hand,

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Journal of Prosthetics and Orthotics Athletic Assistive Technology

Figure 4. Sit ski. Sit skis are generally used by athletes with reduced lower-limb function and stability. Adapted from Cavacece et al.90

developed an upper-limb prosthesis for above-elbow amputees Highsmith et al.98 studied two such examples, determining
to better achieve balance. This group used a simulation of the that the one, the TRS kayak hand (Hammerhead Kayak
crawl stroke and an optimization method to build the upper- Terminal Device, TRS Inc., Boulder, CO, USA), was forgiving
limb prosthesis. of technical errors in paddling form and the other, the USF
Rowing is particularly difficult for athletes with upper-limb kayak hand (University of South Florida), maintained grasp
conditions.97 For amputees, these difficulties have been com- better. In 2008, adaptive rowing became a Paralympic event,
bated in a few ways. Rowing hands must maintain grasp and enabling athletes with physical conditions to compete in
control on the paddle while mimicking human wrist ability.98 rowing competitions using adapted boats.99 These boats often

Figure 5. Swimming prostheses. A, Swimming prostheses must be waterproof and durable. Fin-like attachments are used to improve leg thrust
(top). Durable, rubber attachments with flat bases are used to aid in poolside navigation (bottom). B, An ankle prosthesis conforms to both
walking and swimming. The swimming configuration angles the pylon to be better equipped for water thrust (bottom). Adapted from Saadah94
and Colombo et al.95

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Hill et al. Journal of Prosthetics and Orthotics

include restraints, customizable seats, and gripping aids to technology for athletes without physical conditions, creating
facilitate rowing for AMCs.100 the athlete of the future.

ACKNOWLEDGMENTS
DISCUSSION AND CONCLUSIONS The authors thank all of the affiliates of the Biomechatronics Group
Assistive technology ranges from simple to complicated, and Massachusetts General Hospital Sports Performance Center who
and it alone does not dictate athletic performance; however, assisted in this work.
along with training enhancements, medical advances, the in-
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