Snow Skiing for the Physically Disabled
EDWARD R. LASKOWSKI, M.D., Department of Physical Medicine and Rehabilitation
The sport of snow skiing by the physically disabled, which originated in Europe in 1935 and first received attention in the United States in the 1940s, is reviewed in terms of opportunities available, instructions, adaptive equipment necessary, and benefits provided. Persons with a wide variety of disabilities (such as cerebral palsy, multiple sclerosis, spinal cord injury, hemiplegia, amputation, blindness, spina bifida, and muscular dystrophy) can participate. Accordingly, a wide range of adaptive equipment is available-including outrigger skis, flip-skis, canting wedges, ski bras, "toe spreaders," sit-skis, and mono-skis-to allow safe enjoyment of the sport. Programs for instruction of the disabled skier are increasing in number and popularity, and numerous opportunities are available to enter competitive events sponsored by National Handicapped Sports. Both the participants and the instructors relate the numerous physical and psychologic benefits that can be derived from skiing; the sport provides an almost universal enjoyment of the sense of freedom and independence. Snow skiing is an enjoyable, beneficial, outdoor cold-weather activity that the disabled population can safely learn with proper instruction.
Perhaps Hal O'Leary ofthe Winter Park Handicap Ski Program said it best:
provides many unique physical and psychologic benefits. This review closely examines the sport of snow skiing by the physically disabled in .. .learning to ski is essentially mastering the use of special terms of history, opportunities available, adapequipment and highly developed skills to overcome various tive equipment necessary, instruction, and benenatural difficulties. The skier uses attachments called skis fits provided. to compensate for the inadequate length of his feet. He uses special boots as a supporting prosthesis to overcome the inadequate rigidity of his ankles. A skier must develop skills to keep him upright against the pull ofgravity. When you consider the problems we have to overcome, we're all handicapped skiers.'
HISTORICAL PERSPECTIVE The origins of"handicapped skiing" can be traced to Europe as early as 1935. The concept of "crutch skiing" originated in Switzerland." The Swiss attempted to use underarm crutches for Although everyone may be handicapped to some skiing but eventually discarded this technique. degree in regard to snow skiing, the physically In 1940, Siegfried Drechsler of Austria became disabled have major obstacles to overcome. For known as the first "handicapped" skier. 3 He such persons, however, the experience of skiing apparently skied on one ski after injuring his knee in a downhill race. Franz Wendel, a German, was the first person Address reprint requests to Dr. E. R. Laskowski, Departto compete as a handicapped skier. While servment of Physical Medicine and Rehabilitation, Mayo Clinic, ingwith the German army in 1941, he sustained Rochester, MN 55905. Mayo Clin Proc 66:160-172,1991
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a severe leg injury that necessitated amputation. After reading an article about crutch skiing, he attached short ski tips to the bottom of regular crutches to aid his skiing. These modified crutches were the forerunners of modern day "outriggers," used by handicapped skiers for balance and support. Wendel competed at Berchtesgaden, Germany, in 1942, and in 1943 he received the Handicapped Sports Medal. 3,4 Sepp "Peppi" Zwicknagel, an Austrian, helped advance amputee skiing after losing both legs in a hand grenade injury in World War II.4 He became a certified ski instructor at Kitzbuhel, Austria, and helped to organize demonstrations ofthe amputee skiing technique. By 1947, these demonstrations had become so popular that an annual race at Badgastein, Austria, featured performances by more than 100 handicapped skiers." He also persuaded the Austrian Ski Association to finance a division for the handicapped. Toni Praxmair, Bruno Wintersteller, and Herman Altman are other Austrians who contributed substantially to the growth of amputee skiing." Handicapped skiing in the United States first received attention during the 1940s from World War II casualties. Gretchen Fraser, the first American skier to win an Olympic gold medal (Sweden, 1948), did volunteer work in rehabilitation for two US army hospitals during and after World War II. In 1944 and 1945, she participated in efforts to rehabilitate amputees through skiing. 3,5 In 1953, Jim Winthers, a veteran of the US 10th Mountain Division (an elite corps of light infantry trained for alpine warfare), taught two amputee friends to ski at Donner Ski Ranch in northern California. This became the first ski area in the United States to teach amputees." During the 1950s, the techniques and equipment for handicapped skiing developed rapidly. Paul Leimkuehler, a Cleveland, Ohio, prosthetist and amputee from World War II, was one of the early American pioneers of "three-track skiing" (one ski plus two outriggers). He made outriggers standard equipment for amputee skiers and helped publicize and promote the sport. He is known today as the "Granddaddy of
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Handicapped Skiing" in America, and in 1981, he was the first handicapped skier inducted into the Skiing Hall of Fame." The 1960s saw skiing for the disabled assume a more organized format, with many clubs and clinics beginning to emerge. In Portland, Oregon, the Flying Outriggers Amputee Ski Club was formed. Also during this period, the world's first ski manual for persons with amputations, written by Lee Perry and Hal Schroeder, became an immediate success." The Vietnam War provided the next impetus for the advancement of skiing for the disabled in the United States. In 1968, Dr. Paul Brown and Dr. William Stanek, orthopedic surgeons at Fitzsimons General Hospital in Denver, Colorado, and Denver Children's Hospital, respectively, began programs that used skiing as a rehabilitative technique.' They contacted Willie Schaeffier, who was the ski school director at Arapahoe Basin ski area. Fifteen children from the Amputee Clinic at Children's Hospital in Denver were paired with Vietnam veterans from Fitzsimons General Hospital. A ''buddy system" developed that used the psychology of mutual support and encouragement. Edwin Lucks, one of Schaeffier's senior ski instructors, developed a method of upright skiing for bilateral aboveknee amputees in which control was maintained by hip movement and trunk flexion." By the end of the war, more than 400 military amputees had been taught to ski, including 6 with bilateral above-knee amputations. In early 1970, this program was moved to Winter Park, Colorado, where it remains today. In 1967, Jim Winthers spearheaded a group to form the National Amputee Skier's Association, a nonprofit, tax-exempt corporation designed to unify the disparate groups serving amputee skiers and to provide a framework for their increasing numbers. This organization became the National Handicapped Sports and Recreation Association" (recently shortened to National Handicapped Sports),' which currently has 61 chapters and annuallyservices almost 30,000 people who have a wide variety of disabilities. Advances in adaptive equipment and techniques have now enabled many types of physically dis-
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abled persons to participate in snow skiing, including those with cerebral palsy,multiple sclerosis, muscular dystrophy, visual and hearing impairments, spina bifida, and spinal cord injuries.
METHODS OF ADAPTIVE SKIING Instruction of the physically disabled skier is based on the same technique as those used for able-bodied skiers. The American Teaching Method is the result of many years of research and development in the art of ski instruction by the Professional Ski Instructors ofAmerica. This method is respected worldwide, and adaptive skiing uses the American Teaching Method as its basis. The methods, progression, and technical knowledge all apply to the physically disabled, and the approach can be adapted to the physical capabilities of each student. 7 Assessment of the skier is the first step in adaptive skiing. Those involved in teaching the disabled skier must determine the type and extent of disability, functional limits, adaptive equipment necessary, medications needed, special precautions or problems, and the general physical condition of the skier." This information can be gleaned from physician reports and personal interviews. The following material briefly describes each technique currently available for physically disabled skiing and the adaptive equipment associated with these methods. Three- Track Skiing.-"Three-tracking" has become the most widely known method of skiing for disabled persons (Fig. 1). This method is used for those who have one sound lower extremity and two functional arms (possibly including one upper-extremity prosthesis). Patients who have had an amputation, poliomyelitis, or a traumatic injury or those with hemiplegia are the main participants in three-track skiing. The name originated from the fact that the skier maintains contact with the snow in three placesthe bottom ofthe full-length ski and each of the two short outrigger skis used for balance. The sound lower extremity is attached to the ski, and the other leg, if flail, can be held in place beside the normal leg by a metal shelf. Many three-
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track skiers, however, are above-knee amputees who do not require such a device. The outrigger, popularized in the United States by Leimkuehler, was modified by workers at Fitzsimons General Hospital in the late 1960s so it could double as a crutch for crossing flats or climbing hills. In 1970, Ed Pauls, an Excelsior, Minnesota, ski equipment designer, invented the versatile "flip-ski" (Fig. 2). Flip-skis consist ofLofstrand forearm crutches attached to 50-cm ski tips, with about 30 degrees of movement allowed at the attachment site. With the ski tips in the down position, these outriggers aid in turning and balance. By pulling a lanyard on the handle, the skier is able to lock the ski tips in the upright position." Metal claws on the tails of the ski can then provide gripping and braking action. Flip-skis also assist in loading and unloading chair lifts, standing for prolonged periods, and moving through lift lines. The length of the crutches should be adjusted so that the ski tips hang 2.5 to 5 em above the snow when the skier, wearing equipment, is standing erect and holding outrigger handles." Dr. Duane G. Messner, an orthopedic surgeon and chief adviser, Children's Hospital of Denver rehabilitation programs at Winter Park, allows young patients with below-knee amputations to ski with or without their prosthesis. He has found that 80% of young children choose to participate in three-track skiing without their prosthesis because of better balance and agility and an improved "competitive edge." Those patients with below-knee amputations who begin to ski at an older age (16 to 17 years old) frequently retain their prosthesis, inasmuch as cosmetic factors often are important. 9 Those with above-knee amputations usually ski without a prosthesis. Keeping the stump warm has been a problem for those who wear their prosthesis when they ski. Early trials with leather stump caps were unsuccessful; a double wool sock proved most effective for providing warmth and guarding against injury." For vigorous skiers, pressure sores at the stump end can be prevented by using padded inserts in the socket of the patellar tendon-bearing prosthesis."
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Fig. 1. A and B, Three-track skiing, a method devised for disabled persons with one sound lower extremity and two functional anus. See text for further discussion. (A from O'Leary.f By permission ofthe Winter Park Sports & Learning Center, Inc. B from Cummings K: The 1987 Handicapped Nationals-a gold medal event. Palaestra 3:48-53, Spring 1987. By permission of Challenge Publications, Ltd.)
The below-knee prosthesis should allow the skier's center of gravity to be in front of the ball of the foot. This relationship simulates the position of able-bodied skiers who adjust their center of gravity by bending at the knees, leaning forward, and increasing ankle dorsiflexion. The prosthesis can be given forward lean by placing canting wedges under the heel of the boot. If this technique causes pain in the hamstring area, realigning the prosthesis (moving the socket forward and decreasing overall length) can produce the same functional results with less discomfort. A solid-ankle cushioned-heel foot can be incorporated in the prosthesis because an ankle joint usually is not needed, except by some expert skiers who may desire a four-way joint for additional flexion on steep slopes." For amputees who ski without a prosthesis, lateral canting is sometimes necessary-mainly to compensate for a natural shift of weight. This adjustment consists of canting wedges inserted between the boot and the ski (or in the boot itself) to adjust the lateral or medial tilt of the ski boot on the ski (Fig. 3). A skier with a right aboveknee amputation, for example, tends to shift to
the left and raise the inside of the left foot. This stance places more weight on the left edge ofthe ski and makes right turns difficult. A cant on the inside edge of the left boot allows the shift of weight while maintaining the ski flat. Four- Track Skiing.-The four-track method of skiing is so named because the skier essentially relies on four separate ski sources to get down the hill (Fig. 4). The skier equalizes weight by using two normal skis, and two outriggers are used for additional support. This technique is most often used for patients with cerebral palsy, multiple sclerosis, muscular dystrophy, or myelodysplasia.'" Canting is almost always necessary in this group of patients because of lowerextremity muscle imbalance,and spasticity. The ski bra, invented in 1974, is often used in four-track skiing and in skiing with two skis and two poles ("two-track"). It is most useful for those persons who have difficulty controlling their skis because of muscle imbalance from the hips or knees." A hook is attached to the tip of one ski, and an eyelet is attached to the other. This arrangement allows freedom of movement of the skis but keeps the tips about 7.5 to 10 cm apart and prevents them from crossing. Thus,
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Fig. 2. A and B, Flip-skis, which assist disabled persons with balancing, turning, and stopping. See text for further discussion. (From O'Leary.s By permission of the Winter Park Sports & Learning Center, Inc.)
both snowplow and parallel skiing techniques are easier. For the more advanced skier, a ''bungee-cord'' ski bra can be used. This cord is flexible and allows more mobility of the skis than with the rigid ski bra, and its length can be adjusted as needed. In 1975, the "toe spreader" was devised for skiers who had problems
with scissoring of the legs despite use of the ski bra. This equipment consists of a bar that fits beneath the ski bindings and across the skis; ball bearings are present on either end for easy rotation. The slant board was developed in 1976 for persons who lack flexion in their lower limbs and
Fig. 3. A andB, Canting wedges, which can be inserted between the boot and the ski or in the boot itself. These devices enable handicapped skiers to shift their weight and yet maintain the ski flat. See text for further discussion. (From O'Leary," By permission of the Winter Park Sports & Learning Center, Inc.)
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Fig. 4. A, Four-track skiing, used in patients with cerebral palsy, multiple sclerosis, muscular dystrophy, and myelodysplasia. B, Control lines can be used by instructor to assist beginners with turning and stopping. See text for further discussion.
knees. This board is inserted under the ski bindings to give a forward, backward, or lateral slant to the person's stance. Instructors can help to control the speed and direction of beginning four-track skiers with the use of control lines attached to the student's ski tips. Other essential equipment for the disabled upright skier includes high-quality, properly fitting ski boots and multimodal release bindings. Many neurologically impaired skiers and amputees find that short ski lengths can aid control and maneuverability. Most manufacturers of ski equipment are responsive to special requests; thus, the disabled skier can order single skis and boots and other equipment at a discount. Specialized adaptive equipment is available at ski areas where disabled skiing is taught and can also be ordered through various organizations (see "Resources" at end of this article). The Veterans Administration will supply outriggers for qualified veterans who submit a prescription from a physician. Sit-Skiing.-Currently, persons who require the use of a wheelchair (for example, those with paraplegia or low-level quadriplegia) can downhill ski by two methods-sit-skiing and monoskiing. In 1977, Craig Hospital of Denver, in conjunction with the Winter Park Handicap Ski Program, began experimenting with the use of a
Norwegian cross-country "pulk" (sled) for use in downhill skiing.t''" Peter Axelson, an avid skier who had been injured in a climbing accident that caused paraplegia at the T-10 level, tried the pulk and enjoyed the sensation of moving across the snow under the influence of gravity. The speed and direction of the pulk, however, were not controlled. Therefore, Axelson initiated the development of a series of sit-ski prototypes known as the Arroya. He demonstrated this sit-ski at the 1978 National Handicapped Ski Championships, and the sport immediately began to grow. Between September 1979 and September 1981, the Veterans Administration funded the development of new Arroya models. During the same period, Patrick Smith of Colorado and others developed similar downhill sitskis. The newer designs have improved considerably on the smooth-hulled bottom of the original pulks, and now two sets of bottom edges and runners are used to give the skier better control (Fig. 5). The objective of the sit-ski design is to offer the skier sufficient control to avoid merely "sliding" down the hill as on a sled. The sit-ski must function as a ski, boot, and binding. It should hold the skier tightly in place for better control; have adequate support, cushioning, and padding to prevent decubitus ulcers; and absorb
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Fig. 5. Sit-ski, which can be used by patients with paraplegia or low-level quadriplegia for downhill skiing. See text for further discussion. (From Cummings K: Going for the gold, Eastern style. Sports'n Spokes 13:20-24, May/June 1987. By permission of Paralyzed Veterans of America. Photograph courtesy of Brooks Dodge.)
shock when traversing rough terrain. A knee cushion is used to prevent hyperextension and enhance circulation, and a 2.5-cm sheet of foam may be used to cover the bottom of the sit-ski to slow the conduction of cold. 12 Because the skier rides close to the ground, the sit-ski must have a waterproof cover (such as Gore-Tex) to keep the skier dry. Goggles protect the eyes from flying snow and debris. Adjustable seats can help to customize the sit-ski to the needs of skiers who have various degrees of muscle control. A roll bar is usedfor protection in the event of a fall and in some cases may provide back support. All sitskis should also be equipped with a mechanism to secure the sled to the chair lift for the uphill ride and an evacuation harness that can be used if the chair lift is immobilized. In addition, a helmet should be worn because protection of the head from snow, debris, and errant ski poles is necessary if the sit-ski should roll over. For higher level spinal cord injuries, either bracing or chest straps or harnesses (or both) may be
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needed to compensate for poor stomach and back muscle strength. Patients with quadriplegia as high as incomplete C-5 have successfully used the sit-ski with their hands taped to a kayak pole in a breakaway system (Axelson P: Personal communication, May 23, 1988). To control the speed and direction of the sitski, skiers may use a kayak-type pole, ski grips with a short pick on the end, shortened outriggers, short ski poles (which may vary in length from approximately 18 to 61 em), or brass knuckles with or without a wrist brace. Most sit-skiers seem to prefer short poles or ski grips with short picks. Each of these implements can be used to help initiate turns and to decelerate the sit-ski. Sit-skiers should be properly dressed, preferably in layers of clothing for warmth and versatility. Waterproof gloves or mittens and outerwear are desirable because the skier is close to the snow. Particular attention should be given to ensuring that the feet stay warm. Extra socks, wool socks, and hiking or insulated boots can be used to provide both warmth and protection. Because most sit-skiers lack sensation in their lower extremities, it is important to check their legs and feet periodically (approximately every 2 to 3 hours or as needed, depending on the temperature) to ensure that they are not in danger of frostbite. Instruction in the proper sit-ski technique is specialized. Originally, manufacturers of early models would not allow them to be used without proper instruction. A person could purchase a sit-ski but could use it only at an area that already had an established program. 13 Currently, a person may be tested and certified to ski at any area that allows sit-skis. Instructors can be certified to teach the various techniques of sitskiing, and National Handicapped Sports sponsors sit-ski instructor clinics at areas where established programs exist.J! The Winter Park Handicap Ski Program pioneered the teaching of sit-skiers and originated the concept of'tethering."! With this method, a long tether line is attached to the sit-ski so the able-bodied instructor can help the student turn, stop, and change direction. The tetherer is also able to stop the sitski if the beginning skier loses control. The
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concept is reinforced, however, that the skier learn to ski in control and not depend on the tetherer to extricate him from difficult situations. National Handicapped Sports certifies sit-skiers who demonstrate, to a qualified instructor, their ability to perform safe turns, stops, and rolls on various terrain. Two persons are always needed to lift the sit-skier into the chair lift and assist in unloading. Sit-skiers may also use gondolas, T-bar lifts, and trams to get uphill. In a 1985 survey, sit-skiers had a mean of 16.1 injuries per 1,000 skier days, in comparison with 2.1 injuries per 1,000 skier days for other disabled skiers who did not use the sit-ski.':' Although this statistic may seem excessive, most of the injuries sustained were minor and did not necessitate medical treatment. The type of disability among sit-skiers seems related to the likelihood of injury; most such injuries occur in those with high-level disabilities (T-6 or above). The exposed upper body sustains the brunt of sit-skiing injuries, the most common of which is a sprain or fracture of the thumb.> This injury occurs when the ski pole or hand pick is accidentally driven into the web space between the thumb and index finger (a common injury in nondisabled skiers also).'" Such accidents can be prevented by holding the thumb on the same side of the grip as the other fingers. Most other sit-ski injuries are relatively minor sprains and lacerations. The designers at the Veterans Administration Rehabilitation Research and Development Center in Palo Alto, California, have recommended that persons who have had spinal fusions should refrain from sit-skiing for 1 year after such a procedure. Moreover, obese persons should not participate until body weight is reduced to less than 91 kg, mainly for ease of loading and unloading.!" Mono-Skiing.-The mono-ski is a new piece of adaptive equipment that is now replacing the sit-ski as the skiing technique of choice for most patients with paraplegia (Fig. 6). In simple terms, it is an "orthotic device to replace the knee and ankle" (Axelson P: Personal communication, May 23, 1988). By using this device, pa-
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tients with paraplegia are able to ski in threetrack fashion. Originallydeveloped in West Germany in 1982, the mono-ski was introduced to the United States in 1985. It allows disabled persons to experience the same contact with the snow as able-bodied skiers. The basic design consists of a chassis similar to a sit-ski on which a standard downhill ski is attached. Short, adjustable outriggers are used by the mono-skier for help in balance, control, turning, and stopping. Patients with spinal cord injuries as high as T-2 to T-4 have been able to use the mono-ski; however, those with injuries at higher levels may lack the necessary balance and strength. 2 In patients with injury levels above T-10, a seat belt across the upper chest to midchest area may be desirable, both for support and for control when the skier is leaning forward and sideways and transferring weight for initiation of turns. The skier should fit snugly in the mono-ski, just as an able-bodied foot fits tightly in a ski boot, for maximal control and responsiveness. Beginning mono-skiers should have had some prior experience in the sit-ski. Such previous exposure enables them to read hill terrain better; build strength and endurance in the arms, shoulders, back, and abdomen; practice weighttransfer techniques; and experience loading into and unloading from a chair lift. The latest monoski designs have a self-loading mechanism that simplifies loading into the chair lift and thereby allows the skier to have total independence. The skier uses a crank or lever to raise the mono-ski to chair lift height; thus, the need for lifters is eliminated (Axelson P: Personal communication, May 23, 1988).
BLINDNESS Another group of disabled persons who are capable of being taught to ski in a short time are the visually impaired. They require minimal adaptive equipment and usually become proficient skiers. Approximately 3 of every 1,000 persons in the United States are blind, and programs for integrating the blind into our society are becoming more prevalent. 17 One of these
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Fig. 6. Mono-ski, new adaptive equipment that can be used by patients with paraplegia to experience the same contact with snow as able-bodied skiers. See text for further discussion. (From Crase N: Winter heat. Sports 'n Spokes 15:8-14, May/June 1989. By permission of Paralyzed Veterans of America. Photograph courtesy of Brooks Dodge.)
programs is BOLD, Inc. (Blind Outdoor Leisure tion ofvision. Early in instruction, a ski bra may Development). The Aspen, Colorado, branch of be used to help with balance, but most blind BOLD was created in 1969 by Jean Eymere, a skiers can learn essentially all techniques ofthe senior ski instructor at Aspen Highlands who American Teaching System and are "two-track" lost his sight because of complications of diabe- skiers." As a safety factor, BOLD has designed tes. He once said, "I want to do what everyone a distinctive orangejacket or bib to be worn by all else does. When I ski, I'm free. I feel the wind in blind skiers, instructors, and guides affiliated my face; I fight the bumps with my legs. For a with the program. minute I think I can see again."!" In addition to BOLD and its chapters, the BOLD is a nonprofit Colorado corporation Winter Park Handicap Ski Program has extendedicated to encouraging and helping blind sive experience in teaching the visually impaired. persons engage in outdoor recreation activities Beginning in 1979, blind skiers were allowed to in summer and winter. They now have chapters downhill race with a guide; since then, they have throughout the United States and are continu- competed in events sponsored by National Handally expanding. Aspen is the current headquar- icapped Sports. ters, and trained instructors of the Aspen Skiing Corporation and the Aspen Highlands Skiing Corporation and Ski School provide free instruc- UPPER-EXTREMITY AMPUTATION tion to blind skiers, including beginners, in the Adaptive ski techniques have also been develBOLD program. oped for persons with upper-extremity amputaThe basic adaptation in teaching the blind to tions. These skiers may have difficulty with ski is in the instructor (or "guide") communicat- lateral balance, and steering with the feet and ing through voice and touch to replace the func- legs with minimal rotation of the upper body
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should be emphasized. For safety reasons, persons with above-elbow amputations should ski without a prosthesis. Those with below-elbow amputations may choose to ski with a prosthesis, but a ski pole attached to the prosthesis has not proved successfuL Visualization of pole planting on the affected side often helps in creating balanced turns."
ORGANIZATIONS Programs for the instruction of disabled skiers are increasing in number and popularity, and ample opportunities are available to enter competitive events sponsored by National Handicapped Sports. Teaching clinics and competitive events sponsored by this organization operate on the local, regional, national, and internationallevel to serve physically and visually impaired persons. The participants include patients with amputations, paraplegia, and other mobilityrelated disabilities such as those caused by poliomyelitis, spina bifid a, cerebral palsy, and multiple sclerosis. In 1984, National Handicapped Sports initiated instructor certification for teachers of disabled skiing. The certification program involves academic and practical phases and is endorsed by the Professional Ski Instructors of America. Handicapped skiers, through NationalHandicapped Sports, can now compete against other amateur skiers in races sanctioned by the United States Ski Association at more than 150 ski areas throughout 30 states. In addition to sponsoring an ll-race qualifying schedule leading to the National Handicapped Ski Championships, National Handicapped Sports also sponsors 9 learn-to-ski and instructor's clinics, 8 national leam-to-race clinics, and 10 week-long physical fitness clinics in conjunction with YMCAs in 10 major US cities. IS Classifications for handicapped races take into account a person's disability and the method of skiing (Table 1).19 Thus, in anyone of the classes, persons with various disabilities compete against each other. The use of both medical facts and method of skiing for classification has an equalizing effect on competitors with different disabilities.
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National Handicapped Sports has stimulated the growth of many instructional programs through its learn-to-ski and instructor clinics. A detailed approach to the organization of a ski program for the handicapped has been presented previously by Frank."
THE WINTER PARK EXPERIENCE The Winter Park Handicap Ski Program, initiated in the 1969 to 1970 season with 23 children from Children's Hospital in Denver, Colorado, is the premier program for physically challenged skiers and now accommodates students with 45 different disabilities. The staff of 13 full-time instructors is supplemented by more than 850 interns and volunteers, and approximately 60,000 volunteer hours are donated each year. 2 Approximately 400 lessons are taught each.week to 3,000 skiers annually. In 1986, 13,729 lessons were taught by 850 volunteers and paid instructors." The program sponsors various races and competitions, and many of the racers progress to become part of the United States Disabled Ski Team. Hal O'Leary, director of the Winter Park Handicap Ski Program, has received numerous awards for his outstanding service to and belief in the abilities of persons with disabilities. He recently wrote a 150-page comprehensive manual on teaching skiing to the disabled, entitled Bold Troche? His opinion that handicapped persons are overprotected and seldom allowed to explore their limits is supported by a recent survey of 60 physically disabled high school students in which, given a choice of 19 different risk sports, 31% wanted to participate in downhill skiing. 21 The benefits of handicapped skiing that O'Leary has noted are both psychologic and physicaL "It strengthens their will and gives them something to look forward to. It also lets them compete on the same level as 'normal' people." The physical benefits are considerable as welL Many handicapped persons find it difficult to get adequate exercise, and skiing strengthens their muscles in addition to their will."
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Table 1.-Skiing Classifications for Handicapped Skiers, Established by National Handicapped Sports and the International Sports Organization for the Disabled*
Alpine classes LWl: 4 track (disability of both legs, skiing with outriggers and using two skis or skiing with one ski using a prosthesis) LW2: 3 track (disability of one leg, skiing with outriggers and one ski-use of poles instead of outriggers is allowed) LW3: 2 skis with poles (disability of both legs) LW4: 2 skis with poles (disability of one leg) LW5/7: 2 skis with no poles (disability of both arms or hands) LW6/8: 2 skis with one pole (disability of one arm or hand) LW9: Disability of a combination of arm and leg, using equipment of participant's choice tBl: Totally blind (can distinguish between light and dark, but not shapes) B2: Partially sighted (best correctable vision up to 20/600, visual field of 5 degrees, or both) B3: Partially sighted (best correctable vision from 20/600 to 20/200, visual field from 5 degrees to -20 degrees, or both) Sit-ski and mono-ski classes Group I, class 3 (ISMGF): Disability in lower limbs with injury below T-5 to T-I0 inclusive (also categorized as LWI0) Class 4 (ISMGF): Injury below T-lO to L-3 inclusive (also categorized as LWll) Class 5 (ISMGF): Injury below L-3 to S-2 inclusive (also categorized as LWI2) Group II, alpine classes LWI-4 Class C4 (CP-ISRA): Diplegia Class C5 (CP-ISRA): Moderate paraplegia, severe to moderate hemiplegia, and moderate diplegia Class C7 (CP-ISRA): Moderate to mild lower limb involvement, able to walk without braces, but with spasticity in legs Class C8 (CP-ISRA): Minimal disability in lower limbs caused by incoordination in legs Nordic classes A. Alpine classes LWl-9 and BI-3 B. Sit-ski classes groups I and II *CP-ISRA = Cerebral Palsy-International Sports and Recreation Association; ISMGF = International Stoke Manville Games Federation. t After the 1982 World Winter Games for the Disabled, the international governing body responsible for competition for the blind was the International Blind Sports Association; thus, both that body and the International Sports Organization for the Disabled sanction World Championship and Olympic Games for the Disabled in winter sports. From Benedick.P By permission of Challenge Publications, Ltd.
Larry Kunz is an excellent example ofthe type of success a ski program can achieve. At 9 years of age, he was overweight and wore crutches and leg braces because of spina bifida. He would accompany his friends to the ski slopes, but his participation was limited to buckling their ski boots. Larry's physicians offered little encouragement that he would ever be able to ski, and his fear of failing caused him to shy away from attempting to learn. Permission was obtained from his parents for a trial period of instruction,
and after 6 weeks of training, Larry learned to ski. Numerous obstacles were overcome, even to the point of tying the ends of his skis together to achieve the parallel position that his legs were incapable of maintaining. He has since become an excellent skier; by 14 years of age, he had won the Junior Four-Track National Championship. He had also lost his excess weight, and his recreational involvement strengthened his legs to the extent that he no longer needed crutches to walk."
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CONCLUSION Life for the disabled person can be a constant realization of limitations. The view of handicapped persons has been slowly changing, and this change in attitude is having a major effect on the self-image of disabled persons. Recreation can be a key process for increasing independence and self-confidence. Disabled skiing programs offer mobility-restricted persons the thrill of fluid motion along with speed, grace, and ease not otherwise experienced. The result is often a major accomplishment of utmost importance for the disabled person's psychologic and physical development. In many cases, the exercise, self-confidence, and discipline gained through a handicapped skiing program have dramatically affected a person's life and career opportunities. Furthermore, the sport enables a handicapped person to participate with peers and family members. Benefits are also derived by instructors who assist disabled persons. An able-bodied instructor of the blind stated that" ... the visually impaired share their beautiful thoughts and feelings with the sighted, who in turn share their ability to express forms and colors of objects and nature."23 The camaraderie and closeness that develop between instructor and student can be therapeutic for both. Recent advances in adaptive equipment now enable virtually all categories of physically disabled persons to ski safely. Dr. B. Cairbre McCann, Director of the Department of Medical Rehabilitation at Maine Medical Center, Portland, Maine, said that "Doctors involved in early rehabilitation programs have tended to neglect totally the area of sports... .In a well-organized, quality program of restorative rehabilitation, sports should be available to the individual soon after acquiring the disability." The issue is well summarized by the following quotation: "Due to its gravity-free nature, skiing has become the most successful of rehabilitation sports and recreation programs available to people with disabilities. Skiing and its related associations-writers, industry, athletes, and sponsors-have assured that sports for the disabled will never be the same.?"
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RESOURCES National Handicapped Sports (national headquarters) Suite 717 1145 19th Street NW Washington, DC 20036 (202) 393-7505 Winter Park Handicap Ski Program Hal O'Leary, Director P.O. Box 36 Winter Park, CO 80482 (303) 726-5514, extension 179 Blind Outdoor Leisure Development, Inc. Attn: Edwin H. Lucks 0174 Meadows Road P.O. Box 5429 Snowmass Village, CO 81615 (303) 923-3294
REFERENCES
O'Leary H: The Winter Park Amputee Ski Teaching System. Hideaway Park, Colorado, Hal O'Leary, 1973 2. O'Leary H: Bold Tracks: Skiing for the Disabled. Evergreen, Colorado, Cordillera Press, 20th Anniversary Edition, 1989 3. Lessard B: The history and development of threetrack skiing. In Kick the Handicap-Learn to Ski! A Handbook of Information for the Physically Handicapped (and Others). Second edition. Edited by WE Stieler. Marlette, Michigan, Adapted Sports Association, 1977, pp 6; 105-111 4. Krag MH, Messner DG: Skiing by the physically handicapped. Clin Sports Med 1:319-332, July 1982 5. McConkey J: The concise, authorized history of the National Handicapped Sports and Recreation Association. Handicapped Sports Rep 7:22-26, Winter 1987-1988 6. Brown PW: Rehabilitation of bilateral lower-extremity amputees. J Bone Joint Surg [Am] 52:687-699, 1970 7. National Handicapped Sports and Recreation Association Adaptive Skiing Technique. Washington, DC, National Handicapped Sports and Recreation Association (no date) 8. Kegel B: Sports for the Leg Amputee. Redmond, Washington, Medic Publishing Company, 1986, pp 33-41 1.
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9.
10. 11. 12.
13. 14. 15. 16.
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Ryan AJ, Jackson RW, McCann BC, Messner DG, Beaver DP: Sport and recreation for the handicapped. Physician Sportsmed 6:44-48; 51-55; 58-61, March 1978 Winter Park Handicap Ski Program (informational brochure). Winter Park, Colorado, Winter Park Recreational Association, 1981 Axelson P: Sit-skiing: part I. Sports 'n Spokes 10:2831, JanuarylFebruary 1984 National Handicapped Sports and Recreation Association Sit Skiing Manual. Washington, DC, National Handicapped Sports and Recreation Association (no date) Rappoport A: Skiing by the seat of your pants. Sports 'n Spokes 7:8-13, NovemberlDecember 1981 McConnick DP: Skiing injuries among sit-skiers. Sports'n Spokes 11:20-21, March/April 1985 Browne EZ Jr, Dunn HK, Snyder CC: Ski pole thumb injury. Plast Reconstr Surg 58:19-23, 1976 Axelson P: Sit-skiing: part II. Sports'n Spokes 10: 34-40, March/April 1984
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BOLD, Inc. (informational brochure, Blind Outdoor Leisure Development), Aspen, Colorado, 1981 18. NHSRA (national scene). Palaestra 3:7, Winter 1987 19. Benedick J: Winter sports NHSRA style. Palaestra 1:24-29, Spring 1985 20. Frank LL Jr: Organization and support for a handicapped ski program. Am J Sports Med 10:276-284, 1982 21. Lathen CW, Stoll SK, Hyder M: Do physically disabled individuals desire participation in risk sports? Palaestra 4:19-20; 22-23, Winter 1988 22. Rud K: The Winter Park story: an excellent chronicle on the amazing Winter Park Handicapped Skier Program. In Kick the Habit-Learn to Ski! A Handbook of Information for the Physically Handicapped (and Others). Second edition. Edited by WE Stieler. Marlette, Michigan, Adapted Sports Association, 1977, pp 38-42 23. Eikevik B: Sharing. HEALTHsports, Inc. (infonnational packet), Minneapolis, Minnesota
17.
EDWARD R. LASKOWSKI, M.D., Department of Physical Medicine and Rehabilitation
The sport of snow skiing by the physically disabled, which originated in Europe in 1935 and first received attention in the United States in the 1940s, is reviewed in terms of opportunities available, instructions, adaptive equipment necessary, and benefits provided. Persons with a wide variety of disabilities (such as cerebral palsy, multiple sclerosis, spinal cord injury, hemiplegia, amputation, blindness, spina bifida, and muscular dystrophy) can participate. Accordingly, a wide range of adaptive equipment is available-including outrigger skis, flip-skis, canting wedges, ski bras, "toe spreaders," sit-skis, and mono-skis-to allow safe enjoyment of the sport. Programs for instruction of the disabled skier are increasing in number and popularity, and numerous opportunities are available to enter competitive events sponsored by National Handicapped Sports. Both the participants and the instructors relate the numerous physical and psychologic benefits that can be derived from skiing; the sport provides an almost universal enjoyment of the sense of freedom and independence. Snow skiing is an enjoyable, beneficial, outdoor cold-weather activity that the disabled population can safely learn with proper instruction.
Perhaps Hal O'Leary ofthe Winter Park Handicap Ski Program said it best:
provides many unique physical and psychologic benefits. This review closely examines the sport of snow skiing by the physically disabled in .. .learning to ski is essentially mastering the use of special terms of history, opportunities available, adapequipment and highly developed skills to overcome various tive equipment necessary, instruction, and benenatural difficulties. The skier uses attachments called skis fits provided. to compensate for the inadequate length of his feet. He uses special boots as a supporting prosthesis to overcome the inadequate rigidity of his ankles. A skier must develop skills to keep him upright against the pull ofgravity. When you consider the problems we have to overcome, we're all handicapped skiers.'
HISTORICAL PERSPECTIVE The origins of"handicapped skiing" can be traced to Europe as early as 1935. The concept of "crutch skiing" originated in Switzerland." The Swiss attempted to use underarm crutches for Although everyone may be handicapped to some skiing but eventually discarded this technique. degree in regard to snow skiing, the physically In 1940, Siegfried Drechsler of Austria became disabled have major obstacles to overcome. For known as the first "handicapped" skier. 3 He such persons, however, the experience of skiing apparently skied on one ski after injuring his knee in a downhill race. Franz Wendel, a German, was the first person Address reprint requests to Dr. E. R. Laskowski, Departto compete as a handicapped skier. While servment of Physical Medicine and Rehabilitation, Mayo Clinic, ingwith the German army in 1941, he sustained Rochester, MN 55905. Mayo Clin Proc 66:160-172,1991
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a severe leg injury that necessitated amputation. After reading an article about crutch skiing, he attached short ski tips to the bottom of regular crutches to aid his skiing. These modified crutches were the forerunners of modern day "outriggers," used by handicapped skiers for balance and support. Wendel competed at Berchtesgaden, Germany, in 1942, and in 1943 he received the Handicapped Sports Medal. 3,4 Sepp "Peppi" Zwicknagel, an Austrian, helped advance amputee skiing after losing both legs in a hand grenade injury in World War II.4 He became a certified ski instructor at Kitzbuhel, Austria, and helped to organize demonstrations ofthe amputee skiing technique. By 1947, these demonstrations had become so popular that an annual race at Badgastein, Austria, featured performances by more than 100 handicapped skiers." He also persuaded the Austrian Ski Association to finance a division for the handicapped. Toni Praxmair, Bruno Wintersteller, and Herman Altman are other Austrians who contributed substantially to the growth of amputee skiing." Handicapped skiing in the United States first received attention during the 1940s from World War II casualties. Gretchen Fraser, the first American skier to win an Olympic gold medal (Sweden, 1948), did volunteer work in rehabilitation for two US army hospitals during and after World War II. In 1944 and 1945, she participated in efforts to rehabilitate amputees through skiing. 3,5 In 1953, Jim Winthers, a veteran of the US 10th Mountain Division (an elite corps of light infantry trained for alpine warfare), taught two amputee friends to ski at Donner Ski Ranch in northern California. This became the first ski area in the United States to teach amputees." During the 1950s, the techniques and equipment for handicapped skiing developed rapidly. Paul Leimkuehler, a Cleveland, Ohio, prosthetist and amputee from World War II, was one of the early American pioneers of "three-track skiing" (one ski plus two outriggers). He made outriggers standard equipment for amputee skiers and helped publicize and promote the sport. He is known today as the "Granddaddy of
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Handicapped Skiing" in America, and in 1981, he was the first handicapped skier inducted into the Skiing Hall of Fame." The 1960s saw skiing for the disabled assume a more organized format, with many clubs and clinics beginning to emerge. In Portland, Oregon, the Flying Outriggers Amputee Ski Club was formed. Also during this period, the world's first ski manual for persons with amputations, written by Lee Perry and Hal Schroeder, became an immediate success." The Vietnam War provided the next impetus for the advancement of skiing for the disabled in the United States. In 1968, Dr. Paul Brown and Dr. William Stanek, orthopedic surgeons at Fitzsimons General Hospital in Denver, Colorado, and Denver Children's Hospital, respectively, began programs that used skiing as a rehabilitative technique.' They contacted Willie Schaeffier, who was the ski school director at Arapahoe Basin ski area. Fifteen children from the Amputee Clinic at Children's Hospital in Denver were paired with Vietnam veterans from Fitzsimons General Hospital. A ''buddy system" developed that used the psychology of mutual support and encouragement. Edwin Lucks, one of Schaeffier's senior ski instructors, developed a method of upright skiing for bilateral aboveknee amputees in which control was maintained by hip movement and trunk flexion." By the end of the war, more than 400 military amputees had been taught to ski, including 6 with bilateral above-knee amputations. In early 1970, this program was moved to Winter Park, Colorado, where it remains today. In 1967, Jim Winthers spearheaded a group to form the National Amputee Skier's Association, a nonprofit, tax-exempt corporation designed to unify the disparate groups serving amputee skiers and to provide a framework for their increasing numbers. This organization became the National Handicapped Sports and Recreation Association" (recently shortened to National Handicapped Sports),' which currently has 61 chapters and annuallyservices almost 30,000 people who have a wide variety of disabilities. Advances in adaptive equipment and techniques have now enabled many types of physically dis-
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abled persons to participate in snow skiing, including those with cerebral palsy,multiple sclerosis, muscular dystrophy, visual and hearing impairments, spina bifida, and spinal cord injuries.
METHODS OF ADAPTIVE SKIING Instruction of the physically disabled skier is based on the same technique as those used for able-bodied skiers. The American Teaching Method is the result of many years of research and development in the art of ski instruction by the Professional Ski Instructors ofAmerica. This method is respected worldwide, and adaptive skiing uses the American Teaching Method as its basis. The methods, progression, and technical knowledge all apply to the physically disabled, and the approach can be adapted to the physical capabilities of each student. 7 Assessment of the skier is the first step in adaptive skiing. Those involved in teaching the disabled skier must determine the type and extent of disability, functional limits, adaptive equipment necessary, medications needed, special precautions or problems, and the general physical condition of the skier." This information can be gleaned from physician reports and personal interviews. The following material briefly describes each technique currently available for physically disabled skiing and the adaptive equipment associated with these methods. Three- Track Skiing.-"Three-tracking" has become the most widely known method of skiing for disabled persons (Fig. 1). This method is used for those who have one sound lower extremity and two functional arms (possibly including one upper-extremity prosthesis). Patients who have had an amputation, poliomyelitis, or a traumatic injury or those with hemiplegia are the main participants in three-track skiing. The name originated from the fact that the skier maintains contact with the snow in three placesthe bottom ofthe full-length ski and each of the two short outrigger skis used for balance. The sound lower extremity is attached to the ski, and the other leg, if flail, can be held in place beside the normal leg by a metal shelf. Many three-
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track skiers, however, are above-knee amputees who do not require such a device. The outrigger, popularized in the United States by Leimkuehler, was modified by workers at Fitzsimons General Hospital in the late 1960s so it could double as a crutch for crossing flats or climbing hills. In 1970, Ed Pauls, an Excelsior, Minnesota, ski equipment designer, invented the versatile "flip-ski" (Fig. 2). Flip-skis consist ofLofstrand forearm crutches attached to 50-cm ski tips, with about 30 degrees of movement allowed at the attachment site. With the ski tips in the down position, these outriggers aid in turning and balance. By pulling a lanyard on the handle, the skier is able to lock the ski tips in the upright position." Metal claws on the tails of the ski can then provide gripping and braking action. Flip-skis also assist in loading and unloading chair lifts, standing for prolonged periods, and moving through lift lines. The length of the crutches should be adjusted so that the ski tips hang 2.5 to 5 em above the snow when the skier, wearing equipment, is standing erect and holding outrigger handles." Dr. Duane G. Messner, an orthopedic surgeon and chief adviser, Children's Hospital of Denver rehabilitation programs at Winter Park, allows young patients with below-knee amputations to ski with or without their prosthesis. He has found that 80% of young children choose to participate in three-track skiing without their prosthesis because of better balance and agility and an improved "competitive edge." Those patients with below-knee amputations who begin to ski at an older age (16 to 17 years old) frequently retain their prosthesis, inasmuch as cosmetic factors often are important. 9 Those with above-knee amputations usually ski without a prosthesis. Keeping the stump warm has been a problem for those who wear their prosthesis when they ski. Early trials with leather stump caps were unsuccessful; a double wool sock proved most effective for providing warmth and guarding against injury." For vigorous skiers, pressure sores at the stump end can be prevented by using padded inserts in the socket of the patellar tendon-bearing prosthesis."
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Fig. 1. A and B, Three-track skiing, a method devised for disabled persons with one sound lower extremity and two functional anus. See text for further discussion. (A from O'Leary.f By permission ofthe Winter Park Sports & Learning Center, Inc. B from Cummings K: The 1987 Handicapped Nationals-a gold medal event. Palaestra 3:48-53, Spring 1987. By permission of Challenge Publications, Ltd.)
The below-knee prosthesis should allow the skier's center of gravity to be in front of the ball of the foot. This relationship simulates the position of able-bodied skiers who adjust their center of gravity by bending at the knees, leaning forward, and increasing ankle dorsiflexion. The prosthesis can be given forward lean by placing canting wedges under the heel of the boot. If this technique causes pain in the hamstring area, realigning the prosthesis (moving the socket forward and decreasing overall length) can produce the same functional results with less discomfort. A solid-ankle cushioned-heel foot can be incorporated in the prosthesis because an ankle joint usually is not needed, except by some expert skiers who may desire a four-way joint for additional flexion on steep slopes." For amputees who ski without a prosthesis, lateral canting is sometimes necessary-mainly to compensate for a natural shift of weight. This adjustment consists of canting wedges inserted between the boot and the ski (or in the boot itself) to adjust the lateral or medial tilt of the ski boot on the ski (Fig. 3). A skier with a right aboveknee amputation, for example, tends to shift to
the left and raise the inside of the left foot. This stance places more weight on the left edge ofthe ski and makes right turns difficult. A cant on the inside edge of the left boot allows the shift of weight while maintaining the ski flat. Four- Track Skiing.-The four-track method of skiing is so named because the skier essentially relies on four separate ski sources to get down the hill (Fig. 4). The skier equalizes weight by using two normal skis, and two outriggers are used for additional support. This technique is most often used for patients with cerebral palsy, multiple sclerosis, muscular dystrophy, or myelodysplasia.'" Canting is almost always necessary in this group of patients because of lowerextremity muscle imbalance,and spasticity. The ski bra, invented in 1974, is often used in four-track skiing and in skiing with two skis and two poles ("two-track"). It is most useful for those persons who have difficulty controlling their skis because of muscle imbalance from the hips or knees." A hook is attached to the tip of one ski, and an eyelet is attached to the other. This arrangement allows freedom of movement of the skis but keeps the tips about 7.5 to 10 cm apart and prevents them from crossing. Thus,
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Fig. 2. A and B, Flip-skis, which assist disabled persons with balancing, turning, and stopping. See text for further discussion. (From O'Leary.s By permission of the Winter Park Sports & Learning Center, Inc.)
both snowplow and parallel skiing techniques are easier. For the more advanced skier, a ''bungee-cord'' ski bra can be used. This cord is flexible and allows more mobility of the skis than with the rigid ski bra, and its length can be adjusted as needed. In 1975, the "toe spreader" was devised for skiers who had problems
with scissoring of the legs despite use of the ski bra. This equipment consists of a bar that fits beneath the ski bindings and across the skis; ball bearings are present on either end for easy rotation. The slant board was developed in 1976 for persons who lack flexion in their lower limbs and
Fig. 3. A andB, Canting wedges, which can be inserted between the boot and the ski or in the boot itself. These devices enable handicapped skiers to shift their weight and yet maintain the ski flat. See text for further discussion. (From O'Leary," By permission of the Winter Park Sports & Learning Center, Inc.)
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Fig. 4. A, Four-track skiing, used in patients with cerebral palsy, multiple sclerosis, muscular dystrophy, and myelodysplasia. B, Control lines can be used by instructor to assist beginners with turning and stopping. See text for further discussion.
knees. This board is inserted under the ski bindings to give a forward, backward, or lateral slant to the person's stance. Instructors can help to control the speed and direction of beginning four-track skiers with the use of control lines attached to the student's ski tips. Other essential equipment for the disabled upright skier includes high-quality, properly fitting ski boots and multimodal release bindings. Many neurologically impaired skiers and amputees find that short ski lengths can aid control and maneuverability. Most manufacturers of ski equipment are responsive to special requests; thus, the disabled skier can order single skis and boots and other equipment at a discount. Specialized adaptive equipment is available at ski areas where disabled skiing is taught and can also be ordered through various organizations (see "Resources" at end of this article). The Veterans Administration will supply outriggers for qualified veterans who submit a prescription from a physician. Sit-Skiing.-Currently, persons who require the use of a wheelchair (for example, those with paraplegia or low-level quadriplegia) can downhill ski by two methods-sit-skiing and monoskiing. In 1977, Craig Hospital of Denver, in conjunction with the Winter Park Handicap Ski Program, began experimenting with the use of a
Norwegian cross-country "pulk" (sled) for use in downhill skiing.t''" Peter Axelson, an avid skier who had been injured in a climbing accident that caused paraplegia at the T-10 level, tried the pulk and enjoyed the sensation of moving across the snow under the influence of gravity. The speed and direction of the pulk, however, were not controlled. Therefore, Axelson initiated the development of a series of sit-ski prototypes known as the Arroya. He demonstrated this sit-ski at the 1978 National Handicapped Ski Championships, and the sport immediately began to grow. Between September 1979 and September 1981, the Veterans Administration funded the development of new Arroya models. During the same period, Patrick Smith of Colorado and others developed similar downhill sitskis. The newer designs have improved considerably on the smooth-hulled bottom of the original pulks, and now two sets of bottom edges and runners are used to give the skier better control (Fig. 5). The objective of the sit-ski design is to offer the skier sufficient control to avoid merely "sliding" down the hill as on a sled. The sit-ski must function as a ski, boot, and binding. It should hold the skier tightly in place for better control; have adequate support, cushioning, and padding to prevent decubitus ulcers; and absorb
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Fig. 5. Sit-ski, which can be used by patients with paraplegia or low-level quadriplegia for downhill skiing. See text for further discussion. (From Cummings K: Going for the gold, Eastern style. Sports'n Spokes 13:20-24, May/June 1987. By permission of Paralyzed Veterans of America. Photograph courtesy of Brooks Dodge.)
shock when traversing rough terrain. A knee cushion is used to prevent hyperextension and enhance circulation, and a 2.5-cm sheet of foam may be used to cover the bottom of the sit-ski to slow the conduction of cold. 12 Because the skier rides close to the ground, the sit-ski must have a waterproof cover (such as Gore-Tex) to keep the skier dry. Goggles protect the eyes from flying snow and debris. Adjustable seats can help to customize the sit-ski to the needs of skiers who have various degrees of muscle control. A roll bar is usedfor protection in the event of a fall and in some cases may provide back support. All sitskis should also be equipped with a mechanism to secure the sled to the chair lift for the uphill ride and an evacuation harness that can be used if the chair lift is immobilized. In addition, a helmet should be worn because protection of the head from snow, debris, and errant ski poles is necessary if the sit-ski should roll over. For higher level spinal cord injuries, either bracing or chest straps or harnesses (or both) may be
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needed to compensate for poor stomach and back muscle strength. Patients with quadriplegia as high as incomplete C-5 have successfully used the sit-ski with their hands taped to a kayak pole in a breakaway system (Axelson P: Personal communication, May 23, 1988). To control the speed and direction of the sitski, skiers may use a kayak-type pole, ski grips with a short pick on the end, shortened outriggers, short ski poles (which may vary in length from approximately 18 to 61 em), or brass knuckles with or without a wrist brace. Most sit-skiers seem to prefer short poles or ski grips with short picks. Each of these implements can be used to help initiate turns and to decelerate the sit-ski. Sit-skiers should be properly dressed, preferably in layers of clothing for warmth and versatility. Waterproof gloves or mittens and outerwear are desirable because the skier is close to the snow. Particular attention should be given to ensuring that the feet stay warm. Extra socks, wool socks, and hiking or insulated boots can be used to provide both warmth and protection. Because most sit-skiers lack sensation in their lower extremities, it is important to check their legs and feet periodically (approximately every 2 to 3 hours or as needed, depending on the temperature) to ensure that they are not in danger of frostbite. Instruction in the proper sit-ski technique is specialized. Originally, manufacturers of early models would not allow them to be used without proper instruction. A person could purchase a sit-ski but could use it only at an area that already had an established program. 13 Currently, a person may be tested and certified to ski at any area that allows sit-skis. Instructors can be certified to teach the various techniques of sitskiing, and National Handicapped Sports sponsors sit-ski instructor clinics at areas where established programs exist.J! The Winter Park Handicap Ski Program pioneered the teaching of sit-skiers and originated the concept of'tethering."! With this method, a long tether line is attached to the sit-ski so the able-bodied instructor can help the student turn, stop, and change direction. The tetherer is also able to stop the sitski if the beginning skier loses control. The
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concept is reinforced, however, that the skier learn to ski in control and not depend on the tetherer to extricate him from difficult situations. National Handicapped Sports certifies sit-skiers who demonstrate, to a qualified instructor, their ability to perform safe turns, stops, and rolls on various terrain. Two persons are always needed to lift the sit-skier into the chair lift and assist in unloading. Sit-skiers may also use gondolas, T-bar lifts, and trams to get uphill. In a 1985 survey, sit-skiers had a mean of 16.1 injuries per 1,000 skier days, in comparison with 2.1 injuries per 1,000 skier days for other disabled skiers who did not use the sit-ski.':' Although this statistic may seem excessive, most of the injuries sustained were minor and did not necessitate medical treatment. The type of disability among sit-skiers seems related to the likelihood of injury; most such injuries occur in those with high-level disabilities (T-6 or above). The exposed upper body sustains the brunt of sit-skiing injuries, the most common of which is a sprain or fracture of the thumb.> This injury occurs when the ski pole or hand pick is accidentally driven into the web space between the thumb and index finger (a common injury in nondisabled skiers also).'" Such accidents can be prevented by holding the thumb on the same side of the grip as the other fingers. Most other sit-ski injuries are relatively minor sprains and lacerations. The designers at the Veterans Administration Rehabilitation Research and Development Center in Palo Alto, California, have recommended that persons who have had spinal fusions should refrain from sit-skiing for 1 year after such a procedure. Moreover, obese persons should not participate until body weight is reduced to less than 91 kg, mainly for ease of loading and unloading.!" Mono-Skiing.-The mono-ski is a new piece of adaptive equipment that is now replacing the sit-ski as the skiing technique of choice for most patients with paraplegia (Fig. 6). In simple terms, it is an "orthotic device to replace the knee and ankle" (Axelson P: Personal communication, May 23, 1988). By using this device, pa-
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tients with paraplegia are able to ski in threetrack fashion. Originallydeveloped in West Germany in 1982, the mono-ski was introduced to the United States in 1985. It allows disabled persons to experience the same contact with the snow as able-bodied skiers. The basic design consists of a chassis similar to a sit-ski on which a standard downhill ski is attached. Short, adjustable outriggers are used by the mono-skier for help in balance, control, turning, and stopping. Patients with spinal cord injuries as high as T-2 to T-4 have been able to use the mono-ski; however, those with injuries at higher levels may lack the necessary balance and strength. 2 In patients with injury levels above T-10, a seat belt across the upper chest to midchest area may be desirable, both for support and for control when the skier is leaning forward and sideways and transferring weight for initiation of turns. The skier should fit snugly in the mono-ski, just as an able-bodied foot fits tightly in a ski boot, for maximal control and responsiveness. Beginning mono-skiers should have had some prior experience in the sit-ski. Such previous exposure enables them to read hill terrain better; build strength and endurance in the arms, shoulders, back, and abdomen; practice weighttransfer techniques; and experience loading into and unloading from a chair lift. The latest monoski designs have a self-loading mechanism that simplifies loading into the chair lift and thereby allows the skier to have total independence. The skier uses a crank or lever to raise the mono-ski to chair lift height; thus, the need for lifters is eliminated (Axelson P: Personal communication, May 23, 1988).
BLINDNESS Another group of disabled persons who are capable of being taught to ski in a short time are the visually impaired. They require minimal adaptive equipment and usually become proficient skiers. Approximately 3 of every 1,000 persons in the United States are blind, and programs for integrating the blind into our society are becoming more prevalent. 17 One of these
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Fig. 6. Mono-ski, new adaptive equipment that can be used by patients with paraplegia to experience the same contact with snow as able-bodied skiers. See text for further discussion. (From Crase N: Winter heat. Sports 'n Spokes 15:8-14, May/June 1989. By permission of Paralyzed Veterans of America. Photograph courtesy of Brooks Dodge.)
programs is BOLD, Inc. (Blind Outdoor Leisure tion ofvision. Early in instruction, a ski bra may Development). The Aspen, Colorado, branch of be used to help with balance, but most blind BOLD was created in 1969 by Jean Eymere, a skiers can learn essentially all techniques ofthe senior ski instructor at Aspen Highlands who American Teaching System and are "two-track" lost his sight because of complications of diabe- skiers." As a safety factor, BOLD has designed tes. He once said, "I want to do what everyone a distinctive orangejacket or bib to be worn by all else does. When I ski, I'm free. I feel the wind in blind skiers, instructors, and guides affiliated my face; I fight the bumps with my legs. For a with the program. minute I think I can see again."!" In addition to BOLD and its chapters, the BOLD is a nonprofit Colorado corporation Winter Park Handicap Ski Program has extendedicated to encouraging and helping blind sive experience in teaching the visually impaired. persons engage in outdoor recreation activities Beginning in 1979, blind skiers were allowed to in summer and winter. They now have chapters downhill race with a guide; since then, they have throughout the United States and are continu- competed in events sponsored by National Handally expanding. Aspen is the current headquar- icapped Sports. ters, and trained instructors of the Aspen Skiing Corporation and the Aspen Highlands Skiing Corporation and Ski School provide free instruc- UPPER-EXTREMITY AMPUTATION tion to blind skiers, including beginners, in the Adaptive ski techniques have also been develBOLD program. oped for persons with upper-extremity amputaThe basic adaptation in teaching the blind to tions. These skiers may have difficulty with ski is in the instructor (or "guide") communicat- lateral balance, and steering with the feet and ing through voice and touch to replace the func- legs with minimal rotation of the upper body
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should be emphasized. For safety reasons, persons with above-elbow amputations should ski without a prosthesis. Those with below-elbow amputations may choose to ski with a prosthesis, but a ski pole attached to the prosthesis has not proved successfuL Visualization of pole planting on the affected side often helps in creating balanced turns."
ORGANIZATIONS Programs for the instruction of disabled skiers are increasing in number and popularity, and ample opportunities are available to enter competitive events sponsored by National Handicapped Sports. Teaching clinics and competitive events sponsored by this organization operate on the local, regional, national, and internationallevel to serve physically and visually impaired persons. The participants include patients with amputations, paraplegia, and other mobilityrelated disabilities such as those caused by poliomyelitis, spina bifid a, cerebral palsy, and multiple sclerosis. In 1984, National Handicapped Sports initiated instructor certification for teachers of disabled skiing. The certification program involves academic and practical phases and is endorsed by the Professional Ski Instructors of America. Handicapped skiers, through NationalHandicapped Sports, can now compete against other amateur skiers in races sanctioned by the United States Ski Association at more than 150 ski areas throughout 30 states. In addition to sponsoring an ll-race qualifying schedule leading to the National Handicapped Ski Championships, National Handicapped Sports also sponsors 9 learn-to-ski and instructor's clinics, 8 national leam-to-race clinics, and 10 week-long physical fitness clinics in conjunction with YMCAs in 10 major US cities. IS Classifications for handicapped races take into account a person's disability and the method of skiing (Table 1).19 Thus, in anyone of the classes, persons with various disabilities compete against each other. The use of both medical facts and method of skiing for classification has an equalizing effect on competitors with different disabilities.
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National Handicapped Sports has stimulated the growth of many instructional programs through its learn-to-ski and instructor clinics. A detailed approach to the organization of a ski program for the handicapped has been presented previously by Frank."
THE WINTER PARK EXPERIENCE The Winter Park Handicap Ski Program, initiated in the 1969 to 1970 season with 23 children from Children's Hospital in Denver, Colorado, is the premier program for physically challenged skiers and now accommodates students with 45 different disabilities. The staff of 13 full-time instructors is supplemented by more than 850 interns and volunteers, and approximately 60,000 volunteer hours are donated each year. 2 Approximately 400 lessons are taught each.week to 3,000 skiers annually. In 1986, 13,729 lessons were taught by 850 volunteers and paid instructors." The program sponsors various races and competitions, and many of the racers progress to become part of the United States Disabled Ski Team. Hal O'Leary, director of the Winter Park Handicap Ski Program, has received numerous awards for his outstanding service to and belief in the abilities of persons with disabilities. He recently wrote a 150-page comprehensive manual on teaching skiing to the disabled, entitled Bold Troche? His opinion that handicapped persons are overprotected and seldom allowed to explore their limits is supported by a recent survey of 60 physically disabled high school students in which, given a choice of 19 different risk sports, 31% wanted to participate in downhill skiing. 21 The benefits of handicapped skiing that O'Leary has noted are both psychologic and physicaL "It strengthens their will and gives them something to look forward to. It also lets them compete on the same level as 'normal' people." The physical benefits are considerable as welL Many handicapped persons find it difficult to get adequate exercise, and skiing strengthens their muscles in addition to their will."
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Table 1.-Skiing Classifications for Handicapped Skiers, Established by National Handicapped Sports and the International Sports Organization for the Disabled*
Alpine classes LWl: 4 track (disability of both legs, skiing with outriggers and using two skis or skiing with one ski using a prosthesis) LW2: 3 track (disability of one leg, skiing with outriggers and one ski-use of poles instead of outriggers is allowed) LW3: 2 skis with poles (disability of both legs) LW4: 2 skis with poles (disability of one leg) LW5/7: 2 skis with no poles (disability of both arms or hands) LW6/8: 2 skis with one pole (disability of one arm or hand) LW9: Disability of a combination of arm and leg, using equipment of participant's choice tBl: Totally blind (can distinguish between light and dark, but not shapes) B2: Partially sighted (best correctable vision up to 20/600, visual field of 5 degrees, or both) B3: Partially sighted (best correctable vision from 20/600 to 20/200, visual field from 5 degrees to -20 degrees, or both) Sit-ski and mono-ski classes Group I, class 3 (ISMGF): Disability in lower limbs with injury below T-5 to T-I0 inclusive (also categorized as LWI0) Class 4 (ISMGF): Injury below T-lO to L-3 inclusive (also categorized as LWll) Class 5 (ISMGF): Injury below L-3 to S-2 inclusive (also categorized as LWI2) Group II, alpine classes LWI-4 Class C4 (CP-ISRA): Diplegia Class C5 (CP-ISRA): Moderate paraplegia, severe to moderate hemiplegia, and moderate diplegia Class C7 (CP-ISRA): Moderate to mild lower limb involvement, able to walk without braces, but with spasticity in legs Class C8 (CP-ISRA): Minimal disability in lower limbs caused by incoordination in legs Nordic classes A. Alpine classes LWl-9 and BI-3 B. Sit-ski classes groups I and II *CP-ISRA = Cerebral Palsy-International Sports and Recreation Association; ISMGF = International Stoke Manville Games Federation. t After the 1982 World Winter Games for the Disabled, the international governing body responsible for competition for the blind was the International Blind Sports Association; thus, both that body and the International Sports Organization for the Disabled sanction World Championship and Olympic Games for the Disabled in winter sports. From Benedick.P By permission of Challenge Publications, Ltd.
Larry Kunz is an excellent example ofthe type of success a ski program can achieve. At 9 years of age, he was overweight and wore crutches and leg braces because of spina bifida. He would accompany his friends to the ski slopes, but his participation was limited to buckling their ski boots. Larry's physicians offered little encouragement that he would ever be able to ski, and his fear of failing caused him to shy away from attempting to learn. Permission was obtained from his parents for a trial period of instruction,
and after 6 weeks of training, Larry learned to ski. Numerous obstacles were overcome, even to the point of tying the ends of his skis together to achieve the parallel position that his legs were incapable of maintaining. He has since become an excellent skier; by 14 years of age, he had won the Junior Four-Track National Championship. He had also lost his excess weight, and his recreational involvement strengthened his legs to the extent that he no longer needed crutches to walk."
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CONCLUSION Life for the disabled person can be a constant realization of limitations. The view of handicapped persons has been slowly changing, and this change in attitude is having a major effect on the self-image of disabled persons. Recreation can be a key process for increasing independence and self-confidence. Disabled skiing programs offer mobility-restricted persons the thrill of fluid motion along with speed, grace, and ease not otherwise experienced. The result is often a major accomplishment of utmost importance for the disabled person's psychologic and physical development. In many cases, the exercise, self-confidence, and discipline gained through a handicapped skiing program have dramatically affected a person's life and career opportunities. Furthermore, the sport enables a handicapped person to participate with peers and family members. Benefits are also derived by instructors who assist disabled persons. An able-bodied instructor of the blind stated that" ... the visually impaired share their beautiful thoughts and feelings with the sighted, who in turn share their ability to express forms and colors of objects and nature."23 The camaraderie and closeness that develop between instructor and student can be therapeutic for both. Recent advances in adaptive equipment now enable virtually all categories of physically disabled persons to ski safely. Dr. B. Cairbre McCann, Director of the Department of Medical Rehabilitation at Maine Medical Center, Portland, Maine, said that "Doctors involved in early rehabilitation programs have tended to neglect totally the area of sports... .In a well-organized, quality program of restorative rehabilitation, sports should be available to the individual soon after acquiring the disability." The issue is well summarized by the following quotation: "Due to its gravity-free nature, skiing has become the most successful of rehabilitation sports and recreation programs available to people with disabilities. Skiing and its related associations-writers, industry, athletes, and sponsors-have assured that sports for the disabled will never be the same.?"
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RESOURCES National Handicapped Sports (national headquarters) Suite 717 1145 19th Street NW Washington, DC 20036 (202) 393-7505 Winter Park Handicap Ski Program Hal O'Leary, Director P.O. Box 36 Winter Park, CO 80482 (303) 726-5514, extension 179 Blind Outdoor Leisure Development, Inc. Attn: Edwin H. Lucks 0174 Meadows Road P.O. Box 5429 Snowmass Village, CO 81615 (303) 923-3294
REFERENCES
O'Leary H: The Winter Park Amputee Ski Teaching System. Hideaway Park, Colorado, Hal O'Leary, 1973 2. O'Leary H: Bold Tracks: Skiing for the Disabled. Evergreen, Colorado, Cordillera Press, 20th Anniversary Edition, 1989 3. Lessard B: The history and development of threetrack skiing. In Kick the Handicap-Learn to Ski! A Handbook of Information for the Physically Handicapped (and Others). Second edition. Edited by WE Stieler. Marlette, Michigan, Adapted Sports Association, 1977, pp 6; 105-111 4. Krag MH, Messner DG: Skiing by the physically handicapped. Clin Sports Med 1:319-332, July 1982 5. McConkey J: The concise, authorized history of the National Handicapped Sports and Recreation Association. Handicapped Sports Rep 7:22-26, Winter 1987-1988 6. Brown PW: Rehabilitation of bilateral lower-extremity amputees. J Bone Joint Surg [Am] 52:687-699, 1970 7. National Handicapped Sports and Recreation Association Adaptive Skiing Technique. Washington, DC, National Handicapped Sports and Recreation Association (no date) 8. Kegel B: Sports for the Leg Amputee. Redmond, Washington, Medic Publishing Company, 1986, pp 33-41 1.
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Ryan AJ, Jackson RW, McCann BC, Messner DG, Beaver DP: Sport and recreation for the handicapped. Physician Sportsmed 6:44-48; 51-55; 58-61, March 1978 Winter Park Handicap Ski Program (informational brochure). Winter Park, Colorado, Winter Park Recreational Association, 1981 Axelson P: Sit-skiing: part I. Sports 'n Spokes 10:2831, JanuarylFebruary 1984 National Handicapped Sports and Recreation Association Sit Skiing Manual. Washington, DC, National Handicapped Sports and Recreation Association (no date) Rappoport A: Skiing by the seat of your pants. Sports 'n Spokes 7:8-13, NovemberlDecember 1981 McConnick DP: Skiing injuries among sit-skiers. Sports'n Spokes 11:20-21, March/April 1985 Browne EZ Jr, Dunn HK, Snyder CC: Ski pole thumb injury. Plast Reconstr Surg 58:19-23, 1976 Axelson P: Sit-skiing: part II. Sports'n Spokes 10: 34-40, March/April 1984
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BOLD, Inc. (informational brochure, Blind Outdoor Leisure Development), Aspen, Colorado, 1981 18. NHSRA (national scene). Palaestra 3:7, Winter 1987 19. Benedick J: Winter sports NHSRA style. Palaestra 1:24-29, Spring 1985 20. Frank LL Jr: Organization and support for a handicapped ski program. Am J Sports Med 10:276-284, 1982 21. Lathen CW, Stoll SK, Hyder M: Do physically disabled individuals desire participation in risk sports? Palaestra 4:19-20; 22-23, Winter 1988 22. Rud K: The Winter Park story: an excellent chronicle on the amazing Winter Park Handicapped Skier Program. In Kick the Habit-Learn to Ski! A Handbook of Information for the Physically Handicapped (and Others). Second edition. Edited by WE Stieler. Marlette, Michigan, Adapted Sports Association, 1977, pp 38-42 23. Eikevik B: Sharing. HEALTHsports, Inc. (infonnational packet), Minneapolis, Minnesota
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