Wheelchair basketball (WB) is a Paralympic sport played by two teams of five players each, comprising players with physical impairments who can be allocated to eight different classes (1.0–4.5). The game proceeds at a fast pace, in which, the teams seek to score points in the opponent’s basket. This modality is popular worldwide and has been present in all editions of the Paralympic Games [1]. Due to being a contact sport and due to the sport’s mechanics, in which, frequent shoulder movements are performed (throwing, passing, chair touching), it is expected that this practice contributes to sports injuries.

Sports injuries have both physical and psychological effects that negatively affect sports performance. Once injured, an athlete may need to abstain from the activity, which may vary from days to months [2]. The longer the withdrawal period, the more common it is to observe detraining, as well as a loss of strength and agility. In addition, psychological conditions are also related to injuries, such as anxiety, stress, depression, fear of reinjury and low self-esteem [3]. Therefore, it is important to understand the mechanisms, impact and prevention of sports injuries in Paralympic sports.

A study performed at the London 2012 Paralympic Games observed a variation in the epidemiology of injuries between sports and drew attention to the need for specific longitudinal studies for each of the different modalities [4]. In London 2012, WB recorded 34 injuries, 65% of which were acute injuries, and 23% of which were overuse injuries [5]. In the Rio 2016 Paralympic Games, 4504 interventions were recorded, in which, 399 players were treated by the physiotherapy service. For this competition, eight WB players sought physical therapy, totaling 11 treatments [6], with traumatic injuries being the primary incidents [7].

2. Sports Injury Mechanism

Considering the mechanism, sports injuries can be classified into trauma (traumatic) or overload categories. Traumatic injuries are caused by a single, specific and identifiable event. They can occur with contact (e.g., shock of the body against structures or the opponent’s body) or without contact (e.g., sprain). Overload injuries are caused by repetitive microtrauma, without the identification of a specific event causing the injury. These lesions may have either a sudden or gradual onset ^[8][27]. Among the articles reviewed here, only one clearly described the mechanism of injury. A description of this point is important to understand factors that can lead to the occurrence of injuries, in addition to helping in the prevention process. During sports practice, athletes are exposed to traumatic and overload injuries. In the case of basketball, the biomechanics of the sport itself can influence the appearance of injuries ^[9][28]. The use of the shoulder joint in repetitive movements (propulsion, throwing and passing) can cause the appearance of injuries due to overload. In the same way, sudden changes in direction during movement on the court and the shock with other players can cause the appearance of traumatic injuries. Knowing the biomechanics of the sport helps to minimize injuries and improve sports performance ^[10][11][29,30].

3. Upper Limb Injuries

With the heterogeneity in the reports, many terms were found in the papers describing injuries to the upper limbs. In summary, rwesearchers categorize data of injuries in the fingers, hands, wrists, forearms/arms and shoulders into a single group: upper limb injuries. The highest frequency of WB injuries was in the upper limb, highlighting the shoulder region. These injuries are linked to repeated movements that the sport itself requires, such as the handling of the wheelchair and the biomechanics of the throw in this position ^[9][28]. In addition, the shoulder is an anatomically unstable region, being more prone to injuries ^[12][31]. In WB, the power transmission to the pitch is with the trunk, unlike conventional basketball players, where the force starts in the lower limbs. In the literature, shoulder injuries in wheelchair sports are primary represented by shoulder impact syndrome and rotator cuff injuries ^[13][32] that generate pain, a loss of muscle strength and a decreased range of motion, resulting in changes in biomechanics and positioning, providing muscle shortening and difficulty in performing sports and daily life tasks ^[9][28]. These injuries are related to repetitive movements and force movements performed above the head ^[14][33], activities that are present in WB practice. In addition to the shoulder region, rwesearchers also highlighted injuries to the fingers, hands and wrists, which are primarily represented by fractures and sprains. In general, basketball is a contact sport and therefore promotes the appearance of these injuries, which represents a negative impact on the athlete primarily because it affects the dexterity and skill that an athlete needs to master the ball and perform movements ^[15][34].

4. Head Injuries

The primary head injury observed in these studies was concussion. Sport-related concussion is a traumatic brain injury induced by biomechanical forces and may be caused by either a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head. Symptoms of neurological impairment usually appear quickly and resolve spontaneously; however, these signs and symptoms in some cases can appear over a few minutes to hours. The acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury; therefore, no abnormalities were observed in standard structural neuroimaging exams ^[16][17][35,36]. The signs and symptoms of concussion include loss or not of consciousness, memory impairment, headache, nausea and vomiting, visual disturbances and eye movement, balance impairment and behavioral changes. However, signs and symptoms are not, by themselves, a diagnosis of concussion, and, for suspected diagnosis of concussion, the clinical signs and symptoms cannot be explained by drugs, alcohol, medication use, other injuries or other comorbidities ^[18][19][37,38]. At present, it is known that most athletes are able to recover from clinical symptoms, even in the first month after the injury, but the return to sports needs to occur gradually ^[17][36]. As previously mentioned, basketball is a contact sport, and, for this reason, the incidence rates of concussions in this sport are higher compared to low contact sports. Intervention protocols and behaviors already exist in the literature, such as The Sports Concussion Assessment Tool 5 (SCAT5), which can be used on and off the court ^[18][37]. In addition, rwesearchers emphasize that concussion prevention strategies, such as using specific equipment and changing sport-specific rules to avoid more serious contact, should be carefully considered.

5. Lower Limbs Injuries (Knee, Hip and Ischiatic Region)

Injuries with higher incidence found in the lower limbs included pressure sore injuries, contusions and abrasions on the skin. The appearance of pressure sore injuries is observed in players who depend on the wheelchair for their locomotion and who present sensitivity changes in areas that remain in contact with the chair, primarily ischiatic and sacrum regions; therefore, people with spinal cord injury are the most affected ^[20][21][16,17]. It is important to note that pressure injuries are not exclusive to athletes, but the practice of sports can be a factor that promotes their occurrence. Players with lower classifications usually have greater trunk instability and might be at risk for the occurrence of pressure injuries compared to players of higher classes who, in turn, have better postural control, since these players with lower scores do not experience posture changes, such as tilting the trunk and lowering the pressure points when sitting. These injuries present as a risk factor for poor blood circulation in the region with greater contact with the chair, pressure at specific points for long periods during the day and friction of the skin, and, within sports practice, sweat favors an environment conducive to the development of these injuries. The authors report that, if untreated, these injuries can lead to serious conditions, such as sepsis, and represent the risk of suspension from sports practice until the injury is completely healed ^[21][17]. Regarding bruises and abrasions on the skin, as has been previously indicated, WB is a contact sport where these situations can occur during the game. In certain movements, parts of the metal structure encounter the opponent’s body, which may cause these injuries.

6. Spinal Injuries (Cervical, Thoracic and Lumbar)

Spinal injuries do not seem to be directly related to sports practice, yet the incidence of pain in the spine region, primarily lumbar, in permanent wheelchair users is high, and this population seems to be more susceptible to the onset of this type of pain compared to the general population ^[19][38]. These pain symptoms, both acute and chronic, may be related to the ergonomic characteristics of the chair, since these users spend most of their time sitting in these chairs that might not have the necessary anatomical adjustments, resulting in pain ^[22][39]. In addition to ergonomic factors, it is also necessary to mention factors such as non-physical activity, muscle inactivity and neuropathies ^[19][38]. The prevention of this condition is important because pain negatively affects the quality of life of individuals, and the changes in positioning, the practice of physical activities and the realization of necessary ergonomic adjustments in the chair would be preventive factors for the onset of pain.