Paralympic Classification: An Editorial on the Importance of Classification and Role of Health Care Professionals

Introduction

According to the World Health Organization, there are currently about 1.3 billion individuals with a disability, making up about 16% of the global population. As health care professionals (HCP), we are all caring for individuals with disabilities in our practices. In promoting an active lifestyle and encouraging individuals to maximize their underlying potential, many will choose to pursue recreational and competitive sports. The goal of this editorial is to present to the reader the role of classification in Paralympic sport, its importance, its developmental history, how HCPs play a role, and what concerns HCPs need to consider when performing duties as the patient’s home medical provider, medical/technical classifiers, and medical staff supporting and/or traveling with a team/athlete, which includes team physicians, athletic trainers, physical therapists, sports psychologists, sports dietitians, chiropractors, massage therapists, and others. We start with a case scenario to highlight the importance of understanding classification from various perspectives and roles.

Case scenario

A Paralympic swimmer with a history of mixed spastic/dystonic quadriparetic cerebral palsy has been involved in multiple Paralympic sports and is undergoing international classification review/re-evaluation this year in the sport of Paralympic swimming owing to progressive worsening of her impairment. The athlete has a history of term birth and normal MRI brain and has never had genetic testing performed. Her current sport class in swimming is S4/SB3/SM4. She has appointments with multiple of her medical home HCPs, including her primary care provider and specialists to discuss preparations for her upcoming classification re-evaluation appointment.

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Health care professional role 1: Athlete’s primary HCP and/or specialist HCPs in her medical home. The job of this provider is to figure out how best to support the athlete and may take on many roles, including evaluating if any further diagnostic studies should be pursued, working with the athlete to determine what medical documentation and supporting medical diagnostic studies need to be submitted, and if the athlete needs documentation from other HCPs/specialists.

The athlete travels to an international Paralympic swimming competition in a country that is on the other side of the world from her home country in order to attend her classification evaluation appointment before competition. She travels with part of her team, along with some team staff for support. The athlete arrives at their destination a few days before their classification appointment. During these few days, she eats very little, because of anxiety about the classification process, despite having access to nutritional support from her team sports dietitian and sports psychologist. Unfortunately, on day 3, she has a seizure. The team medical staff activate the emergency response system, and she is evaluated and treated in a local emergency department. It was found that her seizure was provoked and was secondary to hypoglycemia.

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HCP role 2: Medical staff for athletes precompetition, during, and postcompetition (eg, team physician, athletic trainer, physical therapist, sports psychologist, dietitian, chiropractor, massage therapist, and so forth) . These HCPs are responsible for the medical and psychologic care of athletes while traveling with the athlete/team. In the case provided, the HCP needed to evaluate and treat the athlete acutely, including stabilizing the athlete until emergency services arrived, accompanying the athlete to the emergency department, and communicating with emergency medical staff about her medical history and pertinent other information. After the patient is stabilized and acute management is completed, medical staff should consider why this athlete had so much anxiety about the classification process, how they could best support this athlete moving forward, and how this may be prevented in the future.

Because of this medical complication, the athlete’s classification review appointment is postponed until the athlete is deemed medically stable and cleared by a neurologist. She is cleared upon neurology evaluation when she returns home and attends her classification review appointment in another country at a different international competition several months later. She presents to her classification appointment and appears quite anxious but is able to cooperate and participate with full effort in her evaluation. She notes her spasticity and dystonia have significantly worsened since her last classification evaluation.

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HCP role 2: Medical staff for athletes precompetition, during, and postcompetition. As the onsite medical provider, you may be asked to attend the athlete’s classification appointment as her athlete representative. By serving as her representative and chaperone, your task is to figure out how to best support the athlete while also being respectful of the classification panel. Things to consider include what questions are okay to ask, what process should be used if there is concern for a health risk or safety issue for this athlete, and how to advocate for the athlete if questions arise related to the classification process or interpretation. Classification is meant to be a team process, and each group has a role. The athlete’s job is to give an honest effort; the classification panel’s job is to follow standardized guidelines, and as the athlete’s representative and medical staff, your job is to provide data and support. When these members all come together, it results in a successful classification.
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HCP role 3: Medical/technical classifier. As a trained classifier, there is a scripted process that you will need to adhere to. Classifiers need to review information that is presented in this athlete’s medical records and upon presentation decide if the impairment matches the medically documented history. The next step is to review the medical testing/data/evidence supporting the athlete’s medical diagnoses and impairment. The team will factor in other clinical considerations that may impact the overall process. The team will then do a specific physical examination and functional testing maneuvers to better understand the impact the impairment has on the particular sport. During this process, athlete-specific modifications may be implemented owing to the athlete’s unique characteristics. The health and safety of the athlete is of utmost importance. Finally, all these factors are integrated to come up with a presumptive sport class that best matches the athlete’s current eligible impairment and its impact on sport.

Upon completion of her classification review evaluation, the athlete is notified that her classification has remained S4/SM3/SB4 (which is later finalized upon observation in competition), with the plan for her next classification review to be in 2 years owing to her progressive impairment. The athlete is upset, as she thought she had significant decline in their sport function and performance over the past year due to worsened dystonia/spasticity, and felt they should have been classed down. At this time, the athlete also notes that her dystonia and spasticity have significantly worsened after going through the exhausting classification evaluation, and she is having significant pain in multiple areas of her extremities, along with worsened range of motion and function. She is worried about her upcoming performance in competition given her worsened dystonia and spasticity.

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HCP roles 2: Medical staff for athletes precompetition, during, and postcompetition. You again consider as the team’s supporting medical staff how you can best support the athlete, what further medical evaluation and treatments should be performed at this time to address her worsened spasticity and dystonia, how the classification system works for this particular sport, and what the athlete’s rights are in terms of the classification process if they do not agree with the sport class assigned.

This case scenario, while slightly modified from a real-life case to protect athlete privacy, describes what an athlete may experience holistically when going through the classification process from start to finish. Many of the individual components of this case scenario are not uncommon for athletes undergoing classification in certain sports. As you read through this editorial on Paralympic Sport Classification, it is important to consider the many different roles HCPs have in interacting with athletes preclassification, during, and postclassification, and how HCPs may best support athletes in these many roles, while also maintaining the integrity of the classification process.

The importance and background behind Paralympic classification

Sports classification has been an integral aspect of many sports, ensuring equitable competition. In non-disabled sports, factors such as age, sex, and weight are often used to level the playing field for fair competition. Paralympic sports require a much more sophisticated system to ensure that athletes have an opportunity to also compete on a level playing field. Classification is the cornerstone for all Paralympic sports. This sport-specific system groups disabled athletes with similar impairments into competitive groups.

Paralympic sports classification dates back to the 1940s with the emergence of disabled sports. World War II was a brutal war that resulted in a large contingent of combat-related disabling injuries. Dr Ludwig Guttman (the father of the Paralympic Movement) was director of the Spinal Cord Injury Unit at the Stoke Mandeville Hospital in the United Kingdom and a visionary in rehabilitation medicine. He recognized the need for broadening rehabilitation activities in his spinal cord injury (SCI) population to include recreational and competitive sports. Competition is a driving force for the rehabilitation process both internally and externally. Capitalizing on this concept, Stoke Mandeville held the first games in 1948, which was only open to wheelchair athletes with SCI. There was a total of 16 competitors, inclusive of both men and women, and the inaugural event was archery. As this event gained popularity, not only did the number of competitors increase, but the event also grew. Please refer to this link for a quick video on those early years: https://www.paralympicheritage.org.uk/timeline . His vision was to expand into an international competition. This occurred in 1952 when Holland sent down a group of archers to compete at Stoke Mandeville.

As the competition became more organized, the question of how to cluster athletes into groups with similar disabilities emerged. The first system was medically based and introduced in 1952, formally known as the International Stoke Mandeville Wheelchair Sports Federation (ISMWSF). This system was purely based on the athlete’s medical diagnosis for which they were assigned a class. Those with SCIs only competed with other athletes with SCIs. Amputee groups were also testing the waters on classification during these early years.

In the early 1960s, the International Sports Organization for the Disabled (ISOD) was founded, which gave disabled groups not included in ISMWSF an organized competitive structure. These disabilities included athletes with amputations, blindness, and cerebral palsy. As programs matured, the emergence of very specific oversight organizations developed, including the Cerebral Palsy International Sports and Recreation Association (CPISRA) and the International Blind Sports Federation (IBSA). Each of these systems would go on to help develop specific classification programs.

The first Paralympic Games were held in Rome 1960 and essentially included just the group of athletes classed under the ISMWSF system. It was not until the 1976 Paralympic Games that the inclusion of amputee and blind athletes was seen. During the following Paralympic Games in 1980, athletes with cerebral palsy were included in Arnhem, Netherlands. These were the foundational years for each sports disability group to form into their own governing bodies. During this time, each disability group had their own unique medically based classification system, which in essence translated to a lot of events needing to take place during any competition.

In 1982, the multiple sports organizations (ISOD, CPISRA, IBSA, and ISMGF [International Stoke Mandeville Games Federation]) realized that they had a common goal of providing high-quality sports, and there was a need to consolidate programs. This led to the development of the International Coordinating Committee of Sports for the Disabled in the World, which eventually became the International Paralympic Committee (IPC). Also, during this time, there was a shift developing in classification ideology that athletes might be able to be classified based on functional skills. This meant that athletes with different medical diagnoses but similar impairments could be grouped together for competition. This major shift in ideology is the foundation of our current classification system. Multiple sports organizations were mandated to develop a functionally based system for classification. This process was formalized in 1991 so that it could be implemented in 1992 for the Barcelona Paralympic Games. This transition was not without difficulties and even today there are ripple effects from its implementation.

The next step in the evolution of Paralympic classification was to incorporate evidence-based research into better defining classification sports groups. Using evidence-driven research, studying valid measures to test the impact of athletes’ impairments on their function both on and off the field of play transitioned the classification process from a subjective to a more objective, validated system. These measures may include tests of motion analysis, including ones that can be done in a lab, and/or tests specific to activity limitations. A recent example of this is the study done by Caña–Pino and colleagues using surface EMG as a method to identify trends in muscle activity in athletes with cerebral palsy versus a control group. The testing done on football players with cerebral palsy using different activity testing, such as jumping, directional changes, and sprinting, is being used during classification in football to identify characteristics of each athlete that may help define sports class. Although early in its development, such research and implementation into the classification process demonstrated the future focus on refining athlete classification.

The current functional system for classification has been implemented for most Paralympic sports. There are 10 impairments that are recognized as being included in Paralympic sports. They include visual impairment, intellectual impairment, and eight physical impairments: ataxia, athetosis, hypertonia, impaired muscle strength, impaired range of movement, limb deficiency, leg length difference, and short stature. It is important to note that the driving factor behind this system is the impact of the impairment on sports performance. Therefore, some impairments may not be eligible for one sport but may be relevant in a different sport. An example of this is an athlete with a unilateral below-wrist amputation. Based on the impact of the impairment on sport, this athlete would not be eligible for track and field but would be able to compete in swimming. We would be remiss if we did not include here that the system is not defined to include all people who have a disability. There are disabled groups such as the Deaf and Special Olympics athletes that fall outside of the defined impairments and thus are ineligible for Paralympic sports. In addition, the military organizations have developed their own systems for sports classification. Although many military athletes do compete in both Paralympic sports and military games, some impairment groups recognized by the military games would not meet the required impairment criteria under Paralympic sports, such as posttraumatic stress disorder and mild traumatic brain injury. It is worth again mentioning that each Paralympic sport has its own unique classification system based on how the impairment will impact performance in that specific sport.

So, what process does an athlete have to go through to get classified and be eligible to potentially compete and qualify for the upcoming Paralympic Games in Cortina, Italy? The athlete classification evaluation is a well-defined process and outlined in the International Paralympic rules and regulations. Essentially it boils down to three questions outlined by the IPC:

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Does this athlete have an eligible impairment?
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Does the athlete meet the Minimal Impairment Criteria (MIC) for the sport they wish to participate in?
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Which sport class is this athlete allocated based on defined tests, performance, and the defined activities that are fundamental to the sport (based on the sport’s international federation’s current classification protocol)?

The first is they must have an eligible impairment, which is permanent in nature and must be secondary to an eligible medical condition. These include physical, visual, and intellectual impairments. The physical impairment categories are listed in Table 1 , along with example medical conditions that lead to these impairments. Although these impairments are considered eligible under the IPC, each sport will further define which of these impairments are eligible for their particular sport, and the MIC for sports participation.

Table 1

International Paralympic Committee–defined eligible physical impairments

Impairment	Impairment Description	Example Medical Conditions
Ataxia	Athletes have underlying ataxia causing uncoordinated movements	Brain injury Cerebral palsy Strokes Genetic disorders
Athetosis	Athletes have athetosis, which are slow involuntary writhing movements of limbs and trunk	Cerebral palsy Brain injury Stroke Neonatal jaundice
Hypertonia	Athletes have underlying spasticity, dystonia, or rigidity from a central nervous system injury	Cerebral palsy Brain injury Stroke
Impaired muscle power	Athletes will have muscle weakness or paralysis	Spinal cord injury Muscle diseases Polio Spina bifida
Impaired passive range of movement	Restriction in the movements of a joint/joints	Arthrogryposis Arthritis Contractures Trauma
Leg length difference	Leg length difference	Trauma Growth disturbance of limb Congenital limb difference
Limb deficiency	Can be upper or lower extremity Total or partial absence of bones or joints	Traumatic Surgical Congenital limb deficiency Amniotic banding
Short stature	Disorder of growth resulting in short limbs and trunk	Achondroplasia Osteogenesis imperfecta