Defining diagnostic and associated impairment categories

As outlined in the IOC consensus statement,16 the athlete’s impairment type and underlying diagnosis/medical condition must be considered as part of the minimum demographic information collected in Para sport injury and illness surveillance, given that the background diagnosis is often intrinsically related to injury and illness risk and is often poorly recorded or absent.2 4 For example, an athlete with a complete spinal cord injury who uses a wheelchair daily, is at heightened risk of shoulder injury, whereas an amputee athlete is at increased risk for skin injury or illness at the residual limb -socket interface.10 24 25

It is important to note that there remains significant confusion in the sports medicine and research community regarding the difference between diagnosis, eligible impairment category and classification category (sport class). To be eligible to compete in Para sport, first, an athlete must have a diagnosis that could lead to an impairment. This impairment must be one of the 10 eligible impairment types as defined by the IPC classification code (impaired muscle power; impaired passive range of movement; limb deficiency; leg length difference; short stature; hypertonia; ataxia; athetosis; vision impairment and intellectual impairment).26 For purposes of promoting fair competition in Para sport, athletes are grouped into functional categories, or classifications, based on the classification rules of the Para sport Federation, which in turn need to align with the IPC classification code (eligible impairment).26 The aim of this classification is to determine how athletes should grouped for competition, based on the degree of activity limitation resulting from the impairment. Additionally, each Para sport code has classification rules which describe the process by which eligible athletes should be classified.

To determine injury and illness risk, one must identify the underlying diagnosis or pathophysiological process that leads to the eligible impairment (eg, cerebral palsy, which causes athetosis). Whenever possible, information regarding the athlete’s diagnosis should be collected directly via the assessment of a licensed/registered clinician or via evaluation of a clinically verified medical record that allows for this to be confirmed, in preference to athlete or staff self-report.

Since its inception in 1948, the Paralympic movement expanded from a small competition involving only athletes with spinal cord injuries, to include athletes with many different underlying diagnoses.27 Although the range of potential diagnoses in Para sport is vast, for injury surveillance purposes, they must be grouped in a pragmatic way to be used in various global sport settings. This categorisation must be sufficiently specific to allow risk assessment and inform injury and illness prevention strategies. However, if diagnostic categories are divided into very detailed subcategories there is a risk that statistical power will be reduced, and the confidentiality of individuals may be compromised, particularly for those with a unique diagnosis (eg, rare genetic conditions). Figure 1 depicts the current consensus recommendation of how to define and record diagnostic categories for injury and illness surveillance in Para sport.

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Figure 1

Schematic representation of suggested diagnostic categorisation and relation to International Paralympic Committee eligible impairments, for Para sport illness and injury surveillance and monitoring programmes.46 It is recommended that at the very minimum, the large diagnostic or impairment groups as indicated in the double outlined boxes, should be recorded.

Recording of adaptive equipment

Many Para athletes use adaptive equipment in both their daily lives as well as for sports participation. Yet athletes with similar impairment types may or may not elect to use the same kind of adaptive equipment. For example, a unilateral below-knee amputee may either ambulate with a prosthesis or use a wheelchair for daily mobility. Given the intimate athlete-equipment interface and its potential to impact loading and biomechanics, this may have a significant impact on injury or illness risk and should be accounted for in surveillance programmes. Figure 2 depicts the minimum standard consensus recommendations of how to define and record adaptive equipment categories for injury and illness surveillance in Para sport. If an athlete reports using more than one type of adaptive equipment in daily life (eg, manual wheelchair and crutches), the equipment used most frequently should be reported. This scheme does not include various types of sport-specific adaptive equipment (eg, sport-specific prosthesis, mono ski, ice hockey sledge). However, these should be taken into account for research groups wishing to do detailed sport-specific injury and illness risk analyses. Finally, in athletes with vision impairment, the athlete’s guide may also be implicated in the causation of the injury and in these instances, this should be recorded. The recommended categories represented in both figures 1 and 2 are also contained in the example of an injury and illness report from, located in online supplemental appendix 2.

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Figure 2

Schematic representation of suggested mobility aid categorisation for Para sport illness and injury surveillance. ADLs, activities of daily living.

Terminology for health problems

Clarsen et al define an athletic health problem as ‘any condition that reduces an athlete’s normal state of full health, irrespective of its consequences for the athlete’s sports participation or performance or whether the athlete sought medical attention’.28 In contrast, defining ‘health’ for the Para athlete is more complex. Para athletes constitute a heterogeneous population of people with diverse impairments. They do not conform to the WHO definition of health as ‘a state of complete physical, mental and social well-being’.29 A Para athlete by definition, and by the requirement for participation by minimal eligibility criteria, will have an altered baseline state of ‘health’. Thus, an athletic health problem should be recorded when an athlete moves from any state of health, to a ‘less-healthy’ state.30

In the Para athlete, the impairment per se may have associated comorbidities that present in the sporting environment but are not a direct consequence of sport participation itself. While this remains valuable information for healthcare planning, it needs to be considered a confounder in terms of attribution from an epidemiological perspective. The nature of the Para athlete’s impairment may also result in a change in the baseline state of health over time, which might result in different levels of risk for injury or illness (see table 1 for examples of confounders). For these reasons, the consensus group strongly recommends the use of the pre-participation evaluation (PPE), periodic health evaluation and the collection of health data in the form of longitudinal studies.

Defining injury and illness

We concur with the IOC consensus statement’s definitions of injury and illness, but definitions require consideration of whether this relates to the existing impairment in a sporting or non-sporting context, as outlined below.

Relationship to sports activity

We concur with the IOC consensus statement that health problems may result either directly, indirectly, or not at all related to participation in sport. Examples within a Para sport context are shown in table 2.

Mode of onset

Classifying mode of onset

We concur with the IOC consensus statement that data collectors should consider whether a health problem results from a clear acute mechanism, clear repetitive mechanism or a mix of both elements. We have included Para specific examples in online supplemental appendix 3 table A.

Classifying the mechanism of injury

A similar classification system to the IOC consensus statement is applicable, with the subdivision of contact into fixed objects and moving objects, as in the tennis translation of the IOC consensus statement.17 This classification is relevant to various Para sport settings (table 3).

Multiple events, subsequent, recurrent and/or exacerbation of health problems in Para sports epidemiology

The IOC consensus statement emphasises that in sports injury and illness epidemiology, there is a relatively high likelihood that an athlete will experience more than one health problem over a study period.16 Figure 3 of the IOC consensus statement depicts a classification tree for subsequent health problems (adapted from Hamilton et al 31) that is particularly useful in the categorisation of these subsequent injuries/illnesses and exacerbations in sport. In Para sports injury and illness epidemiology, this categorisation is especially relevant. This is because Para athletes experience a higher number of injuries and illness per athlete and due to their health condition also can have a higher number of subsequent injuries, exacerbations, and recurrences of illness and injury.12 32 Therefore, in Para sports injury and illness epidemiology, the following should be recorded for any subsequent injuries: whether it is (1) subsequent recurrent (ie, same injury type as index injury, eg, a recurrent rotator cuff tear); (2) subsequent local injury affecting the same location as the index injury but other tissues (eg, shoulder, but acromioclavicular joint instead of the rotator cuff) or (3) subsequent but affecting other location to the index injury. Recurrent injuries are exacerbations if the index injury is not fully healed.

Similarly, for subsequent illnesses it should be recorded if the subsequent illnesses are (1) subsequent recurrent (ie, same diagnosis as index illness, eg, recurrent urinary tract infection); (2) subsequent local affecting the same system (eg, urogenital) but another diagnosis (eg, catheter site infection or cystitis) or (3) subsequent but other systems. Recurrent illnesses are exacerbations if the index illness has not fully recovered. Examples of subsequent health problems in Para sports injury and illness epidemiology can be found in table 4.

Classifying sports injury and illness diagnoses

We recommend following the IOC consensus statement to classify injury and illness diagnoses. The diagnoses in the IOC consensus statement are based on the Orchard Sports Injury and Illness Classification System (OSIICS), the Sport Medicine Diagnostic Coding System (SMDSC) and the International Classification of Disease (ICD).33 34 These coding systems were recently updated to include some common Para athlete specific codes, for example, common amputation sites. For athletes with amputation or congenital limb anomalies, residual limb injuries can be recorded according to their primary anatomical area, for example, upper or lower limb. Researchers can choose to be more specific and add the specific amputation level, for example, above the knee (transfemoral) or the elbow (transhumeral). An expanded list of all amputations is shown in online supplemental appendix 3 table B.

It is noteworthy that some tissue types and pathology related to Para athletes’ diagnoses are not included as Para athlete specific conditions in the existing systems (OSIICS and SMDCS).33 For example, a pressure ulcer is a frequent and often severe tissue injury that affects athletes with reduced sensation. Among athletes with neurological impairment, joint contractures may be present as well as other nervous system-related injuries.12 35 36 Therefore, we recommend researchers to identify and record the impairment-specific tissue injuries and pathology that may be present in the Para athlete population. See examples in table 5.

It is also possible to use diagnostic codes from the ICD-10 and ICD-11 in instances where diagnoses cannot be found.12 36

Illness: categories for organ system and aetiology

Paralympic athletes have significantly higher rates of illness than their Olympic counterparts with unique medical conditions related to their type of diagnosis, such as autonomic dysreflexia, pressure injuries, neurogenic bladder, premature osteoporosis and neuropathic pain.3 Para athletes also have more skin and subcutaneous lesions related to insensate skin and residual limb/prosthesis interface pathology.24 37 38 For example, non-traumatic skin lesions on the residual limb in amputees, or sunburn/frostbite on insensate skin, need to be categorised separately from other dermatological conditions, and a hypertensive crisis due to autonomic dysreflexia should be recorded separately from common neurological or cardiovascular conditions listed in ICD-10 and ICD-11.

We recommend adding these specific medical conditions in Para athletes as subcategories in existing categories of organ system/region in the IOC consensus statement. For example, insensate skin and/or residual limb can be included as a subcategory of the dermatological system. For cases of autonomic dysreflexia in spinal cord injury or seizure in brain injury, a subcategory of the central nervous system, peripheral nervous system, and autonomic nervous system can be added to the nervous system. We recommend adding a ‘comorbidity of existing diagnosis’ to the categories for aetiology of illness for these unique medical conditions in Para athletes as in table 6.

Time loss from training and competition

We agree with the IOC consensus statement that investigators should consider the strengths and limitations of different approaches and the objectives of their study or surveillance programme, when deciding which severity measures to use. Similarly, we agree with the IOC consensus statement that time loss is the most commonly used criterium for assessment of severity. Online supplemental appendix 3 table C gives practical examples of how to calculate time loss in the Para athlete setting. Using ‘time loss’ for Para athletes has the same limitations as for able-bodied athletes, yet, there are additional considerations and complexities. For example, athletes who use a wheelchair for their sport and sustain an injury to one functional arm may lose independence in daily life, making the impact of such an injury of greater severity than the number of days lost from sport or training alone.

The decision to monitor additional severity parameters, such as non-sport related functional limitations and pain, will depend on the aim of the research. For Para athletes with specific underlying diagnoses, there are outcome measures used in disability research that can be relevant, specifically for evaluation of the impact of the individual’s impairment on their activities of daily living. One such example is the Wheelchair Users Pain Shoulder Index (WUSPI).39 The WUSPI is a simple and effective self-reported questionnaire for rapid assessment of the functional impact of shoulder pain in wheelchair users. Another example is the Sports-related Injury and Illness in Paralympic Sport Study (SRIIPSS) that included self-reported injuries, illnesses, impairment related symptoms and other health parameters such as pain, anxiety, sleep and use of medications.

Para athlete reported symptoms and consequences

Existing tools for able-bodied athletes that allow self-reporting of data (eg, symptom recording and training exposure) require adaptation for the Para sport environment. For example, reporting tools should allow vision impaired athletes and athletes with an intellectual impairment to respond and provide their data on the system. Specific accessibility considerations are described in detail under the section ‘Data collection methods’. Also, some Para athletes with more severe impairments who have higher needs with respect to daily activities might require the assistance of another person to respond and provide data. It should also be possible to include other health symptoms and consequences such as pain, sleep, well-being, medications as well as functional and mental limitations if necessary. An example of one such electronic system is the SRIIPSS eHealth application, which has been specifically developed for all types of Para athletes.13

Recording the severity of health problems based on clinical assessment

As the athlete’s health can fluctuate due to underlying medical conditions and changes in the impairment, we recommend that sufficient baseline data at the time of the PPE are gathered and recorded, to allow a point of reference for the assessment of subsequent health problems. As access to healthcare can vary considerably for Para athletes, the PPE is rarely conducted in some countries. Therefore, it is a challenge to report the subsequent severity of the athletes’ current clinical assessment, as there is no initial benchmark. If baseline health state is unknown prior to the recorded injury or illness, this should be indicated in the injury report. If possible, patient interviews may help identify changes in health state in athletes who do not have well documented health histories. Furthermore, the advent of telemedicine and eHealth approaches might mitigate this particular challenge and may become increasingly popular as an assessment and data collection tool.

Other severity measures

It is important for researchers to consider that certain patient-reported outcome measures for able-bodied athletes cannot be readily used for Para athletes without specific development and testing. One such example is the sports concussion instrument, Sport Concussion Assessment Tool, which cannot be adopted for Para athletes without further development.40 In these instances, we recommend the the adaptation and validation existing sports-related outcome measures for Para athletes.

Accessibility considerations

There are guidelines and regulations in various countries that may facilitate accessibility for web interfaces and mobile applications. In the USA, for example, researchers may collaborate with experts of the Americans with Disabilities Act (ADA), to ensure their surveillance tools meet ADA guidelines. However, to encourage uniformity and ensure accessibility and validity for all data collection methods for Para athletes, we recommended following the Web Content Accessibility Guidelines. To ensure accessibility for athletes with vision impairment, it is recommended to avoid using paper and pen for blind athletes, and scales and pictures must be avoided. These methods can, however, be considered for partially sighted athletes if large text is used. eHealth based data collection can be used advantageously in this population, but it is important to ensure that the method is compatible with multiple devices, speech synthesisers and braille.43 44

For athletes with intellectual impairment, it is important to use data collection methods containing easily understandable terminology and to allow visual cues and free text answers. For some athletes with more severe physical impairments, such as tetraplegia, it is recommended to avoid pen and paper and adapt eHealth based options with assistive technology for writing.44 It is important to consider the provision of support personnel to assist with data collection among some athletes with impairment.43

Finally, the IOC consensus statement highlights the importance of ethics in research and data security. In the context of Para sport, we urge researchers to carefully consider and ensure the protection of dignity and rights of participants, especially as some Para athletes may be considered persons at risk or vulnerable, due to their specific impairment.