Sport for athletes with disabilities has existed for more than 100 years. Today, the global network ‘The Paralympic Movement’ provides sporting opportunities for Paralympic athletes with physical, visual or intellectual impairments, from grassroots to elite level, with the Paralympic Games as the main event. During the past decades, Paralympic sport has seen a large development in both the number of athletes, sports performance and technology [
1], and many Paralympic athletes have reached performances similar to able-bodied elite athletes [
2].
It is well-known that physical activity and participation in sport generates several positive health effects [
3,
4]. Low physical fitness and reduced physical activity is associated with many adverse health events, including major non-communicable diseases [
5]. Participation in sport is therefore of great importance, especially for persons with disabilities, as individuals with a chronic disease or disability have lower physical fitness compared to non-disabled individuals [
6]. Sport is today included in most rehabilitation programs for people with disabilities, to promote both physical and psychological well-being [
7,
8].
Injuries and illnesses in Paralympic sport
Participation in sport is, however, associated with a significant risk for sustaining injuries and illnesses that may have long-lasting effects, including mortality, morbidity and high costs for society [
9,
10]. Remaining free of injury and illness has therefore become a fundamental component of successful performance in sport [
11].
Previous research has shown that injury rates in Paralympic sport are generally high with a trend towards more injuries compared with sport for able-bodied athletes [
12]. Injury patterns related to the impairment, the equipment involved and the specific mechanics of the sport have been proposed to be related to the injuries [
13]. Maintaining health in athletes with already existing disabilities can be problematic. The athletes may have complex pre-existing medical conditions, such as neurodegenerative disorders, spinal cord injury, amputations, rare syndromes with anomalies in different body systems, vision loss and intellectual impairments, and medical issues like autonomic dysreflexia, infections, hyperthermia, skin lesions, spasticity, fatigue, pain and epilepsy can be present [
13]. Moreover, the athletes may be exposed to repetitive and sometimes improper biomechanical load in their daily life [
14,
15]. Based on the facts that the Paralympic Games is now one of the world’s largest multi-sport events [
1] and that training intensity and performance levels have increased during the past years [
16], there are surprisingly few epidemiological studies covering sports-related injuries and illnesses in Paralympic sport. Thus, further studies are needed to ensure the development of safe participation in Paralympic sport.
Sports injury research
Recent research has shown that several categories of sports-related injuries are preventable [
17‐
19]. However, for effective implementation of injury prevention measures, comprehensive epidemiological knowledge is required [
9,
20]. To reduce overtraining, injuries and illnesses, regular monitoring of athletes is an important aspect in athletic preparation [
21,
22]. Although the International Paralympic Committee (IPC) has successfully implemented an epidemiological surveillance system during the Paralympic Games [
23], there is still a lack of longitudinal prospective data following Paralympic athletes over entire training seasons [
12]. A recent review identified large differences in injuries across sports and highlighted the need for sport-specific studies [
24]. Current studies within Paralympic sport vary in quality and have mainly recorded injuries related to trauma, medical attention or time loss. Most studies are retrospective and have only recorded injuries during competitions. In addition, a diversity of injury definitions have been used and most studies have not examined impairment-related risk factors and injury severity [
12,
25]. Thus, there is a need for further longitudinal epidemiological studies that prospectively assess sports-related injuries and illnesses in Paralympic sport based on risk exposure.
Today, most injury surveillance systems exist in professional and commercial able-bodied elite sport settings [
26], for example soccer, tennis and rugby [
27‐
29]. In addition, many of the surveillance systems require that medical practitioners complete the injury report form [
23,
28‐
30]. However, the characteristics, preconditions and contexts differ between sports [
31,
32]. For example, medical attention injuries may be difficult to apply when there is limited access to medical personnel [
33]. It has also been proposed that some methods for injury registration may underestimate overuse injuries [
34]. Also, in terms of injury capture rates, medical staff may underestimate the injury burden compared to athletes themselves [
32].
Athlete monitoring in Paralympic sport
In Paralympic sport everyday access to coaches and medical personnel is scarce [
15] and sport, especially in the Scandinavian countries, is primarily based on voluntary dependency [
35]. Moreover, Paralympic sport has a wide geographical spread, both in Sweden and internationally, and involves more than 28 different sports and 10 different impairments types [
1] (Table
1). In addition, patterns of sports-related injuries and illnesses differ in some ways from those among able-bodied athletes, as the impairment itself is involved in the cause and consequential chains [
15]. The impairment that the athlete has may also cause difficulties in the definition and interpretation of sports-related injuries and illnesses. However, health should not only be related to the absence of a disease or an injury. It also includes the individuals’ capacity to carry out activities in relation to their self-perceived functioning and health [
36].
Table 1
Eligible impairment types and sports in The Sports-Related Injuries and Illnesses in Paralympic Sport Study (SRIIPSS)
Impaired muscle power Impaired passive range of movement | Archery | Athletics | Alpine Skiing |
Boccia | Canoe | Biathlon |
Cycling | Equestrian | Cross Country Skiing |
Limb deficiency | Football-5-a-side | Football-7-a-side | Ice Sledge Hockey |
Leg length difference | Goalball | Judo | Snowboard |
Short stature | Powerlifting | Rowing | Wheelchair Curling |
Hypertonia | Sailing | Shooting | |
Ataxia | Sitting volleyball | Swimming | |
Athetosis | Table tennis | Triathlon | |
Vision impairment | Wheelchair basketball | Wheelchair fencing | |
Intellectual impairment | Wheelchair rugby | Wheelchair tennis | |
Today, there is growing evidence that self-report measures are sensitive and reliable tools to monitor athletes’ health [
22,
37,
38]. For example, Jacobsson and co-workers [
33] reported the development of a web-based self-report system for the Swedish Athletics study. They found that to allow specific analyses of overuse injuries, recording of partial time-loss injuries and regular collection of self-reported data over time was necessary in order to find searches for complex aetiological patterns. It is well-known that many injury-related musculoskeletal incidents result from the cumulative effects of smaller amplitude of micro-traumatic forces developing over time [
39]. Therefore, to prevent injuries and overuse problems to develop into chronic conditions, it is useful to have self-report data that highlights the small and early decrements in functioning [
40]. Also, data on other medical conditions, such as illnesses, training availability and training load, are important to allow us to understand health conditions beyond injuries [
41,
42]. For example, loss of training time due to a health problem has recently been proposed to be a major determinant of success and failure [
42]. Recent research in able-bodied athletes also indicates that a high chronic workload seems to decrease the risk of injuries, whereas excessive and rapid increases in training loads are likely to cause a large proportion of injuries [
43].
With a systematic longitudinal self-report surveillance system based on exposure it would be possible to observe trends and risk factors of sports-related injuries and illnesses in Paralympic sport and thereby have a basis for the development of specific preventive measures. However, for injury surveillance data to be useful for prevention, a theoretical framework is required to understand how factors representative of the target population influence injuries and illnesses [
44]. Moreover, to improve reach, implementation and maintenance it has been recommended that surveillance systems are user friendly and accessible in a wide range of form [
45], in this case adapted for persons with physical, visual or intellectual impairments. To capture all sports-related injuries and illnesses in Paralympic sport, to obtain valid data and to allow specific injury prevention measures, there is a need for injury surveillance systems to be specifically tailored to Paralympic sport, targeting a wide range of para-athletes.