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

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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.
Table 2 lists select aquatics and athletics records and compares
para-athlete records with equivalent Olympic athlete records.
In the Paralympics, competitors are classified on the basis of
ability level and/or condition type. Broadly speaking, the IPC
recognizes six condition categories: amputee, cerebral palsy,
intellectual, wheelchair, visual, and les autres.31 Classifications
differ in every sport and follow a set of guidelines established
and maintained by the IPC. Examples are shown in Table 2 and
are defined as follows:
Aquatics
(numbers move from least ability to most ability)
1 to 10: Physical
11 to 13: Visual
14: Intellectual
Athletics
11 to 13: Blind/visual
20: Intellectual
32 to 38: Cerebral palsy (32Y34 wheelchairs, 35Y38 ambulant)
40 to 46: Amputation or other condition such as dwarfism
(ambulant)
51 to 58: Spinal cord injury or amputation (wheelchair)
Apparent differences exist within the classes of para-athletes
and between athletes with and without physical conditions.
These are highlighted by record comparisons (see Table 2).
Quickly, one can see which conditions affect performance most
severely. In particular, athletes with intellectual conditions seem
to be affected the most, with world records reported only for six
athletic and aquatic events. No other condition affected athletic
performance as drastically as intellectual conditions; however,
ability level is directly linked to the degree and type of condition
and differs for every sport.
Aquatic records follow in an order most would expect. In
all cases, para-athletes post slower records than Olympic ath-
letes. Differences in these records tend to increase with race
distance. For example, in short 50-m races, high-level para-
athletes fall short of Olympic athlete record times by just
greater than 2 seconds (10%), showing that these athletes per-
form at an elite level despite the condition. However, as races
become longer, the disadvantages of para-athletes begin to
show more. Eventually, record time spreads increase to nearly
2 minutes (13%).
On the other hand, athletics records are more interest-
ing. Although they mostly follow the trends seen in aquatics
competition, there are a few unexpected observations. As one
would anticipate, athletes without conditions typically outper-
form para-athletes, especially in jumping and throwing events.
However, a trend begins to arise in longer races (i.e., 800, 1,500,
5,000, and 10,000 m). In these races, some para-athletes have
exceeded Olympic athlete times. The most drastic example of
this occurs in the 10,000-m race, when the fastest para-athlete
outperformed his Olympic athlete counterpart by greater
than 6 minutes (25%). Although this seems counterintuitive
at first glance, upon reviewing the Paralympic classifications
156
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Journal of Prosthetics and Orthotics
(see above), one can notice that each of these high-performing
para-athletes competes using a wheelchair. This gives rise to
two key observations about para-sport and the assistive de-
vices that facilitate them: 1) wheelchairs are currently the
most effective and versatile assistive devices and 2) all as-
sistive devices fall short of consistently reproducing natural
athletic ability.
DESIGN APPROACHES
Designs of assistive devices for athletic activities depend
mostly on the sport, with each differing in the desired tasks and
goals. With this in mind, the following review of assistive device
design approaches is organized according to the general task
and/or sport. The section is split into five major subsections:
wheeled mobility, ambulatory mobility, nonwheeled seated sport,
snow and ice mobility, and aquatic mobility. Wheeled mobility
covers advances in manual wheelchairs, cycling, and powered
wheelchairs. Ambulatory mobility includes recent developments
in running and jumping devices for athletes with lower-limb
conditions. The nonwheeled seated sport subsection discusses
commonly used devices for seated track-and-field sports as well
as fishing. Snow and ice mobility covers skiing and snow-
boarding technology. Finally, aquatic mobility discusses assis-
tive technology for swimming and rowing.
WHEELED MOBILITY
Manual wheelchairs are the most widely used assistive de-
vices for athletes with ambulatory conditions by a substantial
margin. Sports conducted with them include tennis, rugby, cur-
ling, and dance, to name a few. When compared with other
devices, they tend to be more versatile and effective. Their wide-
spread use has led to a number of dedicated publications.32Y36
Years of work have gone into creating ergonomic wheel-
chair designs.32 To accomplish this, wheelchairs are tweaked
to be lighter, faster, and more maneuverable. Advances in ma-
terials and mechanisms have made this possible. Typical wheel-
chairs consist of several customizable components, including
the frame, seat, and wheels. Each one affects performance. Light
frames are essential for acceleration and upper-limb preserva-
tion, seat cushions provide pressure relief for sustained use, hand
rims govern control and propulsion tasks, and casters and
straps provide stability.36Y38 Further, wheel orientation/camber
(Figure 1A) has been shown to affect maneuverability,34,36,41
and seat orientation (Figure 1A) influences stability and con-
trol.34,36 Decisions regarding these parameters differ on the ba-
sis of sport.
Component tweaks, as described above, account for most
sport wheelchair design decisions. Although the decisions to
be made remain the same, the methods for determining them
differ, with some even developing novel devices and experi-
ments to decide.42 Others have explored dedicated designs for
specific communities.43Y45 Berger et al.43 designed a wheel-
chair for basketball players in the Netherlands with a rede-
signed frame to reduce weight and increase strength and an
altered wheel position, angled in such a way that tire defor-
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
use to more wealthy countries and individuals. To combat this,
Authier et al.45 developed a low-cost sport wheelchair for de-
veloping nations. Wheelchair development and selection both
require a specialized and customizable approach based on body
type, activity, and even location.
Para-cyclists have a choice of four different types of cycles:
tandem cycles, tricycles, bicycles, and hand cycles. They all
offer distinct advantages and disadvantages, which depend on
the activity and the condition of the user. Tandem bikes are
made for two riders. There are two seats and two sets of han-
dlebars. Athletes with visual conditions use these; the athlete
sits at the back and a sighted pilot guides from the front. Ath-
letes with balance deficiencies use tricycles. The extra wheel
eases balance, allowing athletes to stabilize in a way that they
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,
but slight modifications are sometimes made to meet the needs
of the condition. Many of these modifications involve custom
attachments between the rider and the bike. Finally, hand cycles
are operated by hand instead of foot. Usually, the rider assumes
a kneeling or lying position.31 We focus only on hand cycles
because either the others are beyond the scope of this article or
limited innovation exists specifically for AMCs.
Hand cycles share many of the same design goals as wheel-
chairs. Like wheelchairs, hand cycles have progressed with ma-
terials and designs. Further, custom component layouts are used
to optimize individual performance. This versatility can be seen
in Sieberts39 work on an adjustable chassis for a mountain hand
bike. As shown in Figure 1B, Siebert alters the tire layout and
builds completely adjustable cranks, footrests, backrests, brack-
ets, and drive trains to allow total customizability in off-road
conditions.
Hand cranks are unique to hand cycles and a major source
of customization. Many have studied the performance differ-
ences caused by altering them.46Y51 These studies typically re-
volve around mechanical efficiency and power effects. Crank
length was studied by Goosey-Tolfrey et al.,46 who determined
that shorter crank lengths tend to be more efficient. Further,
Kramer et al.47,48 analyzed the effects of crank angle and width
on performance in two separate articles, revealing that a more
pronated handle offers improvements, whereas width has min-
imal influence. Arnet et al.49 found that an upright backrest
with a distant crank position reduces shoulder load. Finally,
van der Woude et al.34 measured the effects of gear ratio and
mode on propulsion characteristics and observed a significant
reduction in metabolic expenditure during synchronic arm use
with lighter gear ratios. Hand cranks are a key component of
hand cycles, and, as such, their development over the years has
led to enhanced ability.
Powered assistive sports devices are extremely uncommon.
This makes sense for competitive sports, but for recreational
sports, these are needed to promote activity among popula-
tions with the most serious conditions. So far, the most com-
mon powered devices used for sport are paramobile devices,
those that mobilize paraplegics. These often assist in sitting-
to-standing transitions, and although this may sound minor,
it allows paraplegics to take part in less rigorous standing
activities, such as golf.40,52 Figure 1C displays this transition.
The most common commercial paramobile devices resemble

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Journal of Prosthetics and Orthotics
Perks52 upright wheelchair and use a motorized, tiltable
seat that erects the rider in a manner suitable for swinging a
golf club.
AMBULATORY MOBILITY
With Oscar Pistorius success in the 2012 Olympics came
much coverage of lower-limb prostheses, both as praise and
criticism.53Y58 Some argue that state-of-the-art lower-limb pros-
theses offer amputee athletes distinct advantages when com-
pared with their able-bodied counterparts.56,57 These sentiments
do make a statement about the progress that ambulatory pros-
theses have encountered in recent years; however, they over-
look the progress that remains to be made. This potential for
future development is highlighted by the large amounts of
work still being conducted to further develop running prosthe-
ses. Table 1 shows that wheelchairs are still a very common tool
for athletes with ambulatory difficulties. Future developments in
ambulatory prostheses for athletes seek to open up opportunities
for nonwheelchair athletes that are currently unavailable. Here,
we discuss recent developments.
Passive running prostheses have progressed with materials.
Because modern advances in materials have caused them to
become lighter but stronger, prostheses using these materi-
als can withstand a higher load demand while not inhibiting
the wearer because of weight. In addition, recent innovation
has seen these devices become more biomimetic, but not in
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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Athletic Assistive Technology
appearance.59 Running prostheses, such as the ones shown in
Figure 2, are made to mimic the spring-like behavior of the
human ankle complex, specifically the Achilles tendon,3 but
their form factor is often made to resemble that of a quadru-
pedal animal.60 Using this cheetah architecture, lower-limb
amputees have been able to achieve new athletic heights,3,61,62
inching closer to Olympic levels (see Table 2).
In addition, alignment and residual limb to prosthesis at-
tachment continue to be problems for amputee athletes. No
matter how advanced prostheses become, they are useless with-
out suitable means to attach and align them. To address the first
issue, Burkett et al.63 studied alignment for transfemoral am-
putee runners, showing that lowering the knee joint improves
running velocity and symmetry. New, more intimately attach-
ing sockets have been produced to address the second issue.
Madigan and Fillauer64 designed the 3-S Socket, a silicon suc-
tion socket made for both the upper and lower limbs. Further,
Tingleff and Jensen65 made an adjustable socket from carbon
and polyaramid fibers that uses a slit to form a flexible flap for
readjustment. This socket is made to offer versatility for multi-
ple sports, which require different socket fits. In all cases, the
alignment and socket adjustments were made to optimize ath-
letic performance and fit.
Presently uncommon, powered running prostheses should
become more common in the future. As of now, there is
limited published work. However, Huff et al.66 developed a
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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
require seated technology. Specifically, the throwing sports re-
quire adaptive seats called throwing frames. Limited academic
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,
neither of these studies provides conclusive evidence to im-
prove athlete performance. Others have developed more adjust-
able throwing frames,77 which are hoped to enhance training
and performance.
Fishing is another example of a seated sport that requires
technology manipulations. This has been a significant point of
innovation, particularly among independent inventors. Mecha-
nisms have been developed to assist in holding the fishing
rod,78Y80 casting,81,82 and reeling.83 Examples of these modifi-
cations are shown in Figure 3. For chair users and those with
upper-limb deficiencies, rod stability, power, and control are
critical issues. More recent advances continue to tackle these
problems.84
SNOW AND ICE MOBILITY
Snow and ice activities are extremely popular among AMCs.
For decades, adaptive equipment has been created to account
for these conditions. These adaptations include outriggers/
ski-tipped crutches to stabilize, stirrups for leg support, adap-
tive cuffs for persons with upper-arm conditions, modified boots
and ski attachments for maneuverability, and sit skis with kayak-
style poles for athletes with more severe conditions.85,86 Skiing
prostheses typically focus on facilitating knee and ankle move-
ment while establishing stability.87Y89 Sit skis (Figure 4), on the
other hand, are designed to maintain center of mass stability
and inertia, often using adjustable frames.90,91 These adjust-
ments influence both stability and comfort.90
Figure 3. Adapted fishing rod. The rod comprises a base for stability
and a motored reel for increased power. The fishing rod is rotatable and
adjustable to aid those with mobility conditions. Adapted from Byrd.84
Prostheses for snowboarding are similar to those for skiing.
Versatile leg movement is key. Joint rotation, in all planes, is
essential. Minnoye and Plettenburg92 developed a transtibial
snowboarding prosthesis capable of passive inversion/eversion
and plantarflexion/dorsiflexion to make amputee snowboard-
ing more comparable with snowboarding with biological
limbs. Similarly, St-Jean and Goyette93 developed a passive
multi-axis springed ankle prosthesis for ice skating to im-
prove mobility for a 7-year-old figure skater. Robust multi-axis
joint prostheses are difficult to build, but they are critical for
athletic performance, especially activities that involve snow or
ice mobility.
AQUATIC MOBILITY
Competitive swimming is commonly performed without
assistance. One example is the S3 classification, commissioned
by the IPC, which allows athletes with amputations of all
four limbs to compete against one another.31 However, there
does exist technology designed specifically to assist AMCs
in swimming.
Swimming prostheses (see Figure 5) typically take the form
of fin-like attachments, and many are designed to simplify
navigating the poolside.94 Some have attempted to improve
upon these by making more versatile feet. Colombo et al.95 built
a leg capable of both walking and swimming. The approach
described was an adaptable pylon ankle prosthesis capable of
being manipulated into a fin-like configuration. Figure 5B
shows this adaptation. Yoneyama et al.,96 on the other hand,

160 Volume 26 & Number 3 & 2014

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

Volume 26 & Number 3 & 2014 161

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Hill et al.
include restraints, customizable seats, and gripping aids to
facilitate rowing for AMCs.100
DISCUSSION AND CONCLUSIONS
Assistive technology ranges from simple to complicated,
and it alone does not dictate athletic performance; however,
along with training enhancements, medical advances, the in-
creasing popularity of the Paralympics, and several other fac-
tors, it does play a large role in allowing AMCs to compete at
the highest level. As para-sports progress, we will continue to
see technological advances in assistive devices and athletes
pushing the boundaries of physical limitations, further blur-
ring the line between what people commonly consider dis-
abled and what they do not. Thus far, assistive devices have
been key in producing new levels of performance: lower-limb
amputees are competing with Olympic athletes, Paralympic
records are dropping more rapidly than ever, and wheelchair
athletes have even surpassed some Olympic records. However,
there are limitations.
A look back at the event and record comparisons in Tables 1
and 2 reveals the major limitation of state-of-the-art assistive
technologies for sports. Wheelchairs are by far the most ad-
vanced and widely used devices, as evidenced by the number of
wheelchair sports in the Paralympics and their positive impact
on records; however, even these are vastly limited. Wheel-
chairs confine height, reach, and agility. Despite their con-
straints, wheelchairs clearly outperform other devices for most
Paralympic events. Prostheses may be a better option going into
the future, but as of now, they do not offer the versatile move-
ment capabilities of wheelchairs.
Assistive sports devices have not yet begun to take advan-
tage of smart and/or powered technology. Unlike daily-use
wheelchairs and prostheses that are becoming smarter by in-
corporating electronics, sport devices continue to rely on ad-
vancing materials and mechanical designs. This lack could
be either due to the ethics/purity of sports or due to the dif-
ficulty of producing powered devices suitable for the dynamic
motions required for sports. Moving forward, powered de-
vices may begin to arise in the same way as they have for
general mobility. In addition, these devices will further ex-
ploit the interplay of biology and engineering, closely resem-
bling biology and mimicking biological function. The goal
of these advancements will be for AMCs to meet and surpass
the abilities of competitors with no physical conditions.
Circling back to the original questionVjust how far can
assistive technology enhancements take all athletes in the
futureVwe now see that assistive devices have a long way to go
before they can claim augmentative capabilities. However, the
technology described in this article and used for present-day
assistive devices does have implications in future athletic
augmentation devices. Researchers have already begun to de-
velop devices for the enhancement of dynamic movements.101,102
The progression of these devices is directly tied to that of as-
sistive devices. As assistive technology for athletes compet-
ing with a physical condition advances, so will augmentative
162
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Journal of Prosthetics and Orthotics
technology for athletes without physical conditions, creating
the athlete of the future.
ACKNOWLEDGMENTS
The authors thank all of the affiliates of the Biomechatronics Group
and Massachusetts General Hospital Sports Performance Center who
assisted in this work.
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