Table 1

Examples of medical condition specific to Paralympic athletes in relation to thermoregulation

Diagnosis	Thermoregulation considerations for in-competition performance	Para sport	Reporting of heat-related illness/ symptoms
Spinal cord-related disorders	Impairments in skin blood flow and sweat responses below the lesion level,24 25 reduced venous return,26 and higher body fat will all contribute to increased heat storage for a given workload.27 T_c typically increases continuously throughout competition, as well as passive heating28 (without cooling aids), highlighting the level of thermoregulatory disruption.	Wheelchair Rugby Para Athletics Para Archery Paratriathlon	Heat-related disorientation29 Convulsion5 Heat-related fatigue22 Heat-related illness30
Non-spinal cord-related neurological disorders	Greater metabolic heat production of locomotion, for a given workload, when compared with Olympic athletes.31 High muscular tone impairs venous return, increasing the cardiovascular strain and relative intensity of exercise.32 Impaired pace awareness may increase their risk of thermoregulatory strain.33 Increases in body and/or environmental temperature (without cooling) can exacerbate neurological symptoms, including fatigue, in those with multiple sclerosis,34 where the sudomotor response to heating is already impaired.35	Para Athletics Paratriathlon	Heat exhaustion5 Heat-related illness5 Heat-related illness30
Limb deficiency	Display limited body surface area for evaporative and convective heat loss, increasing heat storage.36 Closer coupling of T_c and T_sk which is further exacerbated by socket liners and prostheses limiting heat dissipation.37 Skin grafts remove a portion of the skin capable of sweating and cutaneous vasodilation, augmenting the impairment in thermoregulatory capacity.38 Significant gait asymmetries, elevating metabolic heat production for a given workload.39	Para Athletics Paratriathlon	Cramps and collapse5 Heat exhaustion5 Heat-related illness5 Heat-related illness30
Visual impairment	Impaired pace awareness (depending on level of visual feedback) may increase their risk of thermoregulatory strain.40 Difficulties in self-monitoring hydration through urine colour or volume may cause issues during competition.41 Athletes with albinism are prone to sunburn in situations of high radiant load. This exacerbates thermal sensation and limits thermoregulation during exercise through a locally mediated effect on sweat gland responsiveness and capacity.42	Para Athletics Paratriathlon	Dermatological burn5 Heat exhaustion5 Heat-related illness5 Heat-related illness30

Grobler et al 5 competitive athletics taking place in wet-globe temperatures 24.6–36.0°C; Griggs et al 29 wheelchair rugby match play at 18.4–20.9°C and 31.1%–45.1% relative humidity; Handrakis et al 22 competitive archery outdoors for 10 hours (conditions not reported); Stephenson et al 30 competitive paratriathlon in 33°C relative humidity 35%–41%. The reader is guided to Westaway et al 43 for lists of medications that can interfere with thermoregulation, dehydration and heat-related illness.
Adapted from Stephenson and Goosey-Tolfrey44 and evidence of heat-related illness reported in Paralympic sports.3 16–18
T_c, body core temperature; T_sk, skin temperature.