A conversation with Dr Euan Speirits
With the Paralympic Games in Tokyo postponed for a year, and, inspired by ‘Rising Phoenix’, the new documentary on the history of the movement, we’ve taken the opportunity to talk with Dr Euan Speirits, an orthopaedic surgeon and athlete physician with a special interest in biomechanics.
He shares his medical perspective on the Games, the technological advances we’re seeing now, and those we might see in the future.
Paralympic sport and medicine are very closely linked, possibly more so than in general athletics. What is your particular area of interest?
As an athlete physician I’m interested in supporting people who want to pursue sport as a professional career. Sometimes, it can be perceived that sport is an aside to a mainstream job, but sport is a true profession and something a person can excel at. That shouldn’t be any different for people who have been attributed to one of the ten Paralympic classes.
I’m interested in developing sports medicine as a field, and when it comes to Paralympics specifically, that’s even more pertinent. Supporting Paralympic athletes and developing the sport requires a lot of data-driven decisions. Considerations include, but aren’t limited to; the competition; what changes to the athlete’s disability means and what would be perceived as an advantage or disadvantage to that person. How we fairly categorise people who would compete against one another is also important. This is key to ensure that all athletes talents are fully utilised. Even small differences in what may be seen as a broad category of, say, an amputation or muscle weakness, can confer quite a major advantage to one athlete over another.
That’s where athlete physicians come in; people who work with these competitors on a regular basis and understand the biomechanics of the human body. It’s important to know the kind of advantages or disadvantages para-athletes may have. Understanding the broad spectrum of conditions they compete with and the resultant impact on their chosen event is key to ensuring athletes reach their full potential. When you add this medical knowledge base to the knowledge and experience of para-athletes who compete at that level under a well informed governing body, everybody gets a better outcome.
So that’s what I’m interested in really; the dialogue between athletes, medics, physios, team coaches and organisers, to ensure everybody has fair and professional competition.
The ethical considerations can be very complex: for instance, the recent case of George Bates, who has complex regional pain syndrome, and has been reclassified and subsequently dropped because he doesn’t meet the new criteria. Other athletes have had to forfeit their careers, because the classification is sometimes very narrow for what can be extremely varied and complex conditions. So as part of the team, how do supporting medics navigate that decision-making process?
It is a very complex issue. When you think about how somebody has gone through everyday life with a disability; that condition has limited their life in so many ways. For them to reach the stage of being a professional athlete within that classification and excelling in sport only to be told they can no longer compete is very significant because that’s their condition then holding them back again.
Trying to decide, for instance in George’s case, whether to physically alter your body in order to compete is a horrendous situation to be put in. Personally, I tell people to avoid surgery in every single possible case unless it is giving them a medical benefit. The idea of doing it for a sporting benefit is a relatively new concept, and I hope the decision will be driven by the symptoms and long term benefits. As swiftly as categorisations and qualifications change in one direction, they may change back just as swiftly. As the pool of Paralympic athletes increases, and we understand more about how varying severity of conditions impact that sport, there may be another classification fairly shortly afterwards.
The idea of altering yourself in order to fit a classification, only for it to change or have the potential to change, is a huge ethical conundrum.
Does the element of sport impact that decision?
Absolutely. For other people’s professions, one of the first questions we ask is ‘what do you do for a living?’ as it changes how a medic approaches a condition. Professional athletes are just as driven as FTSE 100 CEOs in terms of what they want from their careers. It’s a case of ‘this is my life, this is what I do, this is my complete inherent drive for how I live and what I want to be’, so the idea of having that changed is incomprehensible. It’s their entire life. As their physician, you have to consider whether they are going to be able to continue their profession based on the medical outcome you give them. You must understand your athlete. The more you know them on a personal and professional level, the better equipped you are to assist them in making medical decisions. There are many areas and influences that can feed into this process.
Looking at the other side of ethical decision-making, how does the sport and medical team start to make a decision whether a prosthetic or intervention is going to enable a natural ability, or confer an unfair advantage?
It’s very difficult to put multiple athletes in the same group. One of the most obvious categories is runners who have lost a leg. We’ve seen several high-profile athletes with bilateral prostheses and a wide range of prostheses available. At that point, you have different technologies available to different people from diverse backgrounds. It can arguably become a technology race rather than a physical prowess race or true measure of athletic ability.
These differing opportunities have always been prevalent across non para sports and always will be. At the most basic level, imagine a young gymnast from a wealthy background. Their parents can drive them to gymnastics practice in a high level performance club with top of the line facilities from age five and the road to a professional sporting career will be paved for them. That person has an unfair technological and financial advantage compared to somebody who may just be as talented and focussed as them, but doesn’t have the socio-economic background to support them.
So we have to rely on the fact that things will gradually even themselves out. Society has changed hugely in our approach to people who are differently enabled and fairness has increased compared to 50 years ago (although there is still a lot of progress to be made). Addressing this is now conferring an effect. People with disabilities are better able to financially support themselves to get into sports and the opportunities for entering para sports are greater. This is largely due to how well the Paralympics are promoted and how sponsor interest is starting to come in at a comparable degree to other professional sports. As investment increases, we will hopefully start to see a levelling of the playing field between available technologies with, for instance, top 800 m runners all on an optimum leg.
From your perspective, what do you think has been the most significant change/intervention in terms of your area of interest i.e. biomechanics?
There have been lots of changes for people with a disability in general outside of sport. In terms of the electronics and biomechanics for prostheses; the invention of the superconductor, the condensing of battery technology, increasing computing power, and now, what we’re seeing in terms of artificial intelligence and really small controlled circuit boards. We have prostheses where people can actually feel through the bottom of a prosthetic foot!
These technological advances are affecting how we do surgery. If you look at a fairly recent surgical development, the Ewing Amputation—a planned below-knee amputation for people with a prosthesis in mind—rather than having an amputation and engineering the prosthesis to it, we’re now thinking in advance ‘how is this person going to best fit a prosthesis when we are done with this procedure?’.
Obviously that’s not available in the case of traumatic/unplanned/emergency amputations, but when you can plan in advance and know that the person is going to have a prosthetic below-knee for the rest of their life, you can preserve the musculature, nervous function to those muscles and the relationships of the muscles to tendons. That person can then have control over a prosthetic foot using the small amount of residual muscle they have below the knee. That’s a gigantic change and a huge shift in how were see things done and the direction of surgery/amputation/prosthetic, and we are truly looking at human-machine interfacing. Cybertronics is going to be the big medical buzzword of the 21st century.
That neatly leads on to what you think the main areas of research are going to be going forwards?
We now have technology that is condensable, reliable, can power itself for longer and is better at making its own decisions. The size and the usability compared to just 10 to 15 years ago is huge, and then when you consider what Elon Musk is doing with Neuralink – we really are becoming cyborgs.
The application for people with disabilities, and then for them getting into sports—that’s the difference between somebody 20 years ago who had a life-altering disability and may never function as they did before and potentially, in 20 years’ time, outperforming a normal human leg— that’s very exciting.
What other developments might we see, particularly in relationship to sport?
Variations on the above. The thing is, when you design a prosthetic, you can usually design it to be very good at one particular thing. It’s very hard to mimic how adaptable and fluid an organic leg would be—I’m using legs as an example, but hands and arms are a far more complex problem—and we will hopefully start to see the development of modular systems; legs you can plug on for different situations that are just that much more exceptional at doing that one specific thing.
The blade leg is a commonly seen example for runners, and that technology will just get better and better. We have already had conversations around trying to quantify how much force blades can produce, and whether it is more force than somebody who doesn’t have a below-knee amputation could produce. Is it conferring an unfair advantage? Could people with below-knee amputations start racing in the Olympics without the need for a disability class? That’s a great situation to be in – I see that as an exciting challenge brought about by how good our technology has become.
How do you measure these factors when there is such variability between human beings? How do you start to create a framework around that data?
It will depend on what problem you’re trying to solve. We have multiple different classes to qualify someone as a Paralympian, but this is still relatively new. The idea of human competition without any categorisation is thousands and thousands of years old, and when you set that alongside Paralympic competition which is now 75 years old, that’s a comparatively small reference frame to go on.
If you look at subsequent leaps in terms of how many Paralympians are competing at each Games and the competition levels within each category, it will grow as an exponential curve. When you start to have enough people within each category and consistency between subsequent Olympic years, then you can start to narrow down what’s making the difference between people. That’s still difficult to do, as reclassification is a constant thing. There was a point when somebody with an amputated leg was put in a broad class for amputated legs, regardless of the level of amputation. Now we have the ability to say that someone is within a certain class of amputation, allowing them compete fairly against others with that same level of disability.
It will evolve, I think, as more and more athletes see this as a viable career opportunity, and societally we shift to a point where fair opportunities are consistently available. As this happens, and we have more input from athlete teams and organisers along with better communal understanding, things will become far more competitive.
As a final question, when we at last get to see the Tokyo Paralympics in 2021, which sport will you be watching most closely?
I do really like watching wheelchair basketball. I played basketball at university, so I have a slight bias, but it’s remarkable watching how problems are overcome and how people have not been held back simply because a traditional framework didn’t exist.
At some point, someone was sat in a wheelchair at the side of a basketball court thinking that was something they could never do. Then came problem-solving; determined athletes, engineers to help with designing chairs, organisers reviewing rules to ensure fair structures for competition and physicians ensuring their athletes are healthy whilst troubleshooting any problems that arise with increasingly competitive competition.
The amount of human effort that goes into achieving that is remarkable. It’s really cool to see what traditionally would be a barrier being deconstructed. Problems are solved to the point where people with a disability can have a viable professional career in sport.
Paralympic sport and its ‘Superhumans‘ have been extraordinary. It’s inspiring for very positive reasons; the creativity and the approach to challenges, rather than just focussing on the ways in which a person might be limited.
Absolutely – as people we are trained to spot differences; we have a horrible habit of making them binary i.e. you can or you can’t, it’s a yes or a no. There’s been no middle ground, no way of us finding something where actually what we perceive as a ‘no’, is a ‘yes’ somewhere else. As more of these opportunities present themselves we will see more people being exceptional in their own way. Just because a swimmer has a short stature or somebody has a muscle weakness, it doesn’t mean that they can’t succeed. All that is needed is the correct field of play alongside people with shared life experience that they can excel with.
The biggest thing we have done is societally is to rearrange how we view disability, and I’m really hoping that momentum continues to grow. London 2012 was a really big landmark point as you say, and it’s stuck with me how much Channel 4 positively promoted what these athletes are great at. I think it was a great launch point into contemporary public consciousness.
The London 2012 Olympics were fabulous, but the Paralympics were mind-blowing. Why do think that was?
We always want to see what has never been done before. As humans we crave that, I think. It’s why people pay to go and watch professional sport. We want to see people excelling at what they do, and when you think about—for example, Usain Bolt and the 100m final—the percentage difference in what he did was not gigantic. When you compare it to the Paralympics, where we genuinely see lots of things that we’ve never seen in sport before—people absolutely destroying what were perceived as their limitations as a human—that is incredibly exciting.
These developments in human-machine interfacing assisting people with their disabilities and helping them perform exceptionally are going to be a landmark part of sport for the 21st century.
Dr Euan Speirits is the founder of Action Sports Medical and Orthopaedic Research Fellow, Registrar and PhD student at University of Strathclyde and Golden Jubilee Research Institute.
He is also a World Cup competitor in mountain bike (MTB) downhill racing.
Rising Phoenix premiered on Netflix 26th August
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