While sport has value in everyone's life, it is even more important in the life of a person with a disability. This is because of the rehabilitative influence sport can have, on the physical body, and on rehabilitating into society. Nowadays, sports and physical activity found its way in rehabilitation, and individuals with a disability participate in high-performance as well as in competitive and recreational sport across the world. The Paralympic Games, originated from sports complementary to physical rehabilitation, are the pinnacle event.1

Paralympic athletes can be categorised in different groups, each requiring a particular approach with regard to medical care: athletes with loss of limb or limb deficiency (eg, amputation), athletes with loss of muscle power (eg, spinal cord injury, postpoliomyelitis, spina bifida), athletes with coordination problems (eg, hypertonia, ataxia, or athetosis as clinically manifested in, for example, cerebral palsy), athletes with visual impairment and athletes with intellectual impairment.

With participation in sport comes an associated risk of injury. Despite the growing awareness and popularity of disability sport, there continues to be a relative paucity to understanding the injury patterns and risk factors for injury among these athletes.2 The (advances in) use of assistive propulsion and protective devices, as allowed by the sport technical rules (orthotic or prosthetic devices, wheelchairs, throwing chairs, sitskis, sledges, use of goggles, …) brings an additional component of medical care which should be considered throughout (eg, the influence on the stump-socket interface on the prosthesis and the body). Also not-so-obvious compensatory factors require further attention. Amputation in the lower leg alters the orientation of the pelvis, in turn altering the orientation of the vertebral column. This may have far-reaching consequences on the functional ability of the athlete, and requires the evaluation of technology in a holistic manner.3

Although Paralympic athletes can experience the same spectrum of medical conditions as athletes without disabilities, furthering the understanding through longitudinal and systematic investigation of injuries and illnesses in elite athletes is extremely helpful in this regard.2 4 For example, a comparatively ‘routine’ shoulder overuse injury that might be a mere ‘nuisance’ for an able-bodied athlete may compromise the ability of a C6-lesion tetraplegic athlete (athlete with high neck lesion, impacting the function of both lower and upper limbs) to remain independently mobile, to say nothing about dramatically interfering with his or her participation in sport (Van de Vliet P, Pit-Grosheide P, Martinez-Ferrer O. Sports Medicine and Physical Challenge 2012. In: FIMS Team Physician Manual, edited by Professor Lyle Micheli, submitted November 2011)

The medical care in Paralympic athletes should be related to the sport-specific risks and demands as well as to the nature of the impairment. Though relatively few studies are available, wheelchair track and road racing, para cycling, alpine skiing, wheelchair basketball and wheelchair rugby are among the higher risk sports.2 4 Besides the occasional repetitive stress on joints and muscles and the accidental injury from incidental crashes involving wheelchair, sitskis or prostheses, certain groups of Paralympic athletes are prone than others to sensory disorder and skin breakdown, thermoregulation and dehydration problems, bladder dysfunction, osteoporotic fractures, blood pressure, oedema, autonomic dysreflexia and (still too often) inappropriate fitting into the device (Webborn ADJ, Van de Vliet P. Paralympic Medicine. Lancet 2012; under review) Caution should be given to a possible prolonged recovery from injury due to osteoporosis, blood flow challenges and reduced physical activity levels in initial rehabilitation phases.

Whereas team physicians should emphasise injury-prevention techniques, pharmacological management of athletes with a disability should not be forgotten. Pharmacological literature unfortunately does not offer much relevant information concerning the effects of medication on exercise performance in disabled athletes, and data on medication use in this athlete group are not systematically available. Additionally, Paralympic athletes in first instance are athletes and thus bound by the same rules, regulations and responsibilities as any other athlete under the World AntiDoping Code. As with any medical treatment, it is recommended that individuals who may benefit from these medications be treated by a specialist with extensive knowledge of the individual's condition and that periodic review of the individual's status is necessary to ensure that the correct treatments are being administered in the correct dose.6 7

With the growth of the Paralympic Movement, athletes with exceptionally diverse categories of disability are more frequently travelling great distances to compete on the world stage. In addition to sport-specific training, preparation for travel and maximising one's ability to arrive at a competition refreshed and ready to perform are essential components of an athlete's success and require specific attention.2 This includes discussing current medication prescriptions, need for extra prescriptions to bring along in the case your travel is unexpectedly prolonged or medication being unavailable on site, medications or supplies that may necessitate special arrangements with airline staff, medical supplies such as catheters, gloves and necessary immunisations for the region to which you are travelling. Athletes should also address the level of (venue and accommodation) accessibility at destination.

Besides the medical care, sport medicine in the Paralympic Movement should also consider the psychological component of disability sport. Research on athletic identity has demonstrated that although many athletes with a disability view themselves as committed and serious athletes, they typically feel that the public does not view them as legitimate athletes. The ramifications of an inadequate coaching support system are that athletes may need extra support and (medical) care.8 This certainly applies when an athlete leaves the sport and transitions back to ‘individual’ in daily life.

A better understanding of common disabilities and injuries will assist athletes, their coaches, therapists and trainers as well as all event (medical) staff in identifying possible medical problems and activities that may lead to injuries or medical complications. This enables all involved to take the steps necessary to ensure safe and effective training techniques and maximise competitive performance on the one hand, and optimise sports medicine and event-related medical services on the other hand.

The International Paralympic Committee (IPC) has committed to performing injury and illness surveillance programmes at Paralympic Games, which will provide insight into injuries occurring during elite events. Such survey already was conducted in Paralympic Winter Games9 10 and will now be initiated in Paralympic summer sports during the London 2012 Paralympic Games. In addition, the Paralympic Movement has adopted the IPC Medical Code11 to ensure athlete health and safety becomes more prominent part of future developments in Paralympic sports. It goes without say that the information obtained must find its way to the athletes and their support staff to safeguard future competition, athlete careers and postcareer active lifestyles.