Sean M. Tweedy

International Paralympic Committee position stand—background and scientific principles of classification in Paralympic sport

The Classification Code of the International Paralympic Committee (IPC), inter alia, mandates the development of evidence-based systems of classification. This paper provides a scientific background for classification in Paralympic sport, defines evidence-based classification and provides guidelines for how evidence-based classification may be achieved. Classification is a process in which a single group of entities (or units) are ordered into a number of smaller groups (or classes) based on observable properties that they have in common, and taxonomy is the science of how to classify. Paralympic classification is interrelated with systems of classification used in two fields: ▶ Health and functioning. The International Classification of Functioning, Disability and Health is the most widely used classification in the field of functioning and health. To enhance communication, Paralympic systems of classification should use language and concepts that are consistent with the International Classification of Functioning, Disability and Health. ▶ Sport. Classification in sport reduces the likelihood of one-sided competition and in this way promotes participation. Two types of classification are used in sport—performance classification and selective classification. Paralympic sports require selective classification systems so that athletes who enhance their competitive performance through effective training will not be moved to a class with athletes who have less activity limitation, as they would in a performance classification system. Classification has a significant impact on which athletes are successful in Paralympic sport, but unfortunately issues relating to the weighting and aggregation of measures used in classification pose significant threats to the validity of current systems of classification. To improve the validity of Paralympic classification, the IPC Classification Code mandates the development of evidence-based systems of classification, an evidence-based system being one in which the purpose of the system is stated unambiguously; and empirical evidence indicates the methods used for assigning class will achieve the stated purpose. To date, one of the most significant barriers to the development of evidence-based systems of classification has been absence of an unambiguous statement of purpose. To remedy this, all Paralympic systems of classification should indicate that the purpose of the system is to promote participation in sport by people with disabilities by minimising the impact of eligible impairment types on the outcome of competition. Conceptually, in order to minimise the impact of impairment on the outcome of competition, each classification system should: ▶ describe eligibility criteria in terms of: ⊳ type of impairment and ⊳ severity of impairment; ▶ describe methods for classifying eligible impairments according to the extent of activity limitation they cause. To classify impairments according to the extent of activity limitation they cause requires research that develops objective, reliable measures of both impairment and activity limitation and investigates the relative strength of association between these constructs in a large, racially representative sample. The paper outlines a number of objective principles that should considered when deciding how many classes a given sport should have: the number of classes in a sport should not be driven by the number of athletes in a sport at a single time point.

A prospective, longitudinal study of growth, nutrition and sedentary behaviour in young children with cerebral palsy

BackgroundCerebral palsy is the most common cause of physical disability in childhood, occurring in one in 500 children. It is caused by a static brain lesion in the neonatal period leading to a range of activity limitations. Oral motor and swallowing dysfunction, poor nutritional status and poor growth are reported frequently in young children with cerebral palsy and may impact detrimentally on physical and cognitive development, health care utilisation, participation and quality of life in later childhood. The impact of modifiable factors (dietary intake and physical activity) on growth, nutritional status, and body composition (taking into account motor severity) in this population is poorly understood. This study aims to investigate the relationship between a range of factors - linear growth, body composition, oral motor and feeding dysfunction, dietary intake, and time spent sedentary (adjusting for motor severity) - and health outcomes, health care utilisation, participation and quality of life in young children with cerebral palsy (from corrected age of 18 months to 5 years).Design/MethodsThis prospective, longitudinal, population-based study aims to recruit a total of 240 young children with cerebral palsy born in Queensland, Australia between 1st September 2006 and 31st December 2009 (80 from each birth year). Data collection will occur at three time points for each child: 17 - 25 months corrected age, 36 ± 1 months and 60 ± 1 months. Outcomes to be assessed include linear growth, body weight, body composition, dietary intake, oral motor function and feeding ability, time spent sedentary, participation, medical resource use and quality of life.DiscussionThis protocol describes a study that will provide the first longitudinal description of the relationship between functional attainment and modifiable lifestyle factors (dietary intake and habitual time spent sedentary) and their impact on the growth, body composition and nutritional status of young children with cerebral palsy across all levels of functional ability.

Paralympic classification: conceptual basis, current methods, and research update.

Paralympic classification systems aim to promote participation in sport by people with disabilities by controlling for the impact of impairment on the outcome of competition. Valid systems of classification ensure that successful athletes are those who have the most advantageous combination of anthropometric, physiological, and/or psychological attributes, and who have enhanced them to the best effect. Classification systems that are not valid pose a significant threat to Paralympic sport and, therefore, the International Paralympic Committee (IPC) has a Classification Code which includes policy commitment to the development of evidence‐based methods of classification. The aim of this article is to provide an overview of current best practice in classification for athletes with physical impairments, and to update research advances in the area. Currently, classification has 4 stages: (1) establish whether the athlete has a health condition that will lead to one or more of the 8 eligible types of physical impairment, (2) determine whether the athlete has an eligible impairment type, (3) determine whether the impairment is severe enough, and (4) determine in what class the athlete should compete. A sequential 4‐step process that outlines how to initiate and develop evidence‐based methods of classification is described: (1) specification of impairment types that are eligible for the sport; (2) development of valid measures of impairment(s); (3) development of standardized, sport‐specific measures of performance; and (4) assessment of the relative strength of association between measures of impairment and measures of performance. Of these, the development and reporting of valid measures of impairment is currently the most pressing scientific challenge in the development of evidence‐based methods of classification.

Boosting in athletes with high-level spinal cord injury: knowledge, incidence and attitudes of athletes in paralympic sport

Autonomic dysreflexia (AD) is unique to individuals with spinal injuries (SCI) at T6 or above and can be voluntarily induced. Although AD improves wheelchair racing performance in some athletes, it also elicits exaggerated blood pressure, which could be dangerous. The International Paralympic Committee considers AD doping and banned its use. Purpose. The purpose of this study is to evaluate AD knowledge, incidence and attitudes (KIA) of Paralympians with SCI. Methods. An existing questionnaire was modified to include questions of AD KIA, validated by three experts and piloted with a small sample. It was administered on-line, mailed to members of a scientific network and distributed during the Beijing Paralympic Games. Fisher Exact test was used to evaluate differences across gender, injury and education. Results. Of 99 participants, 54.5% had previously heard of AD while 39.4% were unaware; 16.7%, all males, had used AD to enhance performance. Participants reported that AD was (1) useful for middle (78.6%) and long distance (71.4%), marathon (64.3%) and wheelchair rugby (64.3%); (2) somewhat dangerous (48.9%), dangerous (21.3%) or very dangerous (25.5%) to health. Results were not influenced by age, injury level or injury duration. Conclusions. Findings indicate the need for educational programmes directed towards enhancing the AD knowledge of rehabilitation professionals, coaches and trainers working with SCI individuals.

Towards evidence-based classification in Paralympic athletics: evaluating the validity of activity limitation tests for use in classification of Paralympic running events

Objective: To classify Paralympic athletes, classifiers use test batteries to obtain an objective, pre-competition estimate of an athlete’s training level. Five tests were evaluated to determine which combination explained the maximum variance in running performance in a non-disabled population. A non-disabled sample was required to permit psychometric evaluation of the tests without the confounding influence of impairment, and to provide an indication of normative performance. Design: Sixty-seven non-disabled participants (male and female; mean (SD) age 24.78 (6.53) years) completed a six-test battery comprising a 30 m sprint (criterion activity limitation test) and five supplementary activity limitation tests: standing broad jump, four bounds, 10 m skip, running in place and split jumps. Results: Test reliability was high for all tests (intraclass correlations  =  0.80–0.99). Pearson correlations with the 30 m sprint were moderate to strong for standing broad jump (−0.82), four bounds (−0.80) and 10 m skip (0.67), but weaker for split jumps (0.35) and running in place (0.19). Multiple regression indicated that standing broad jump, four bounds and 10 m skip explained 75% of the variance in running performance. Conclusions: The test battery is reliable and valid in the non-disabled population and therefore has potential utility in Paralympic classification. Test results were normally distributed, a necessary prerequisite for meaningful interpretation of future studies in athletes with impairments. Further studies evaluating the battery in populations of athletes with impairments of coordination, strength and range of movement are now warranted.

Measurement of habitual physical activity performance in adolescents with cerebral palsy: a systematic review

Aim  This systematic review compares the validity, reliability, and clinical use of habitual physical activity (HPA) performance measures in adolescents with cerebral palsy (CP).

Towards evidence-based classification in wheelchair sports: Impact of seating position on wheelchair acceleration

Abstract In most Paralympic wheelchair sports, active trunk range of movement is assessed by observing shoulder girdle excursion during active trunk movements and is a key determinant of an athletes class. However, to date research evaluating the impact of reduced trunk range of movement on wheelchair sports performance has not been conducted. In the present study, 15 non-disabled male participants performed two 20-s sprints on a wheelchair ergometer in each of three seating positions. Positions were typical of those used to enhance sitting stability in wheelchair sport and each impacted available trunk range of movement differently: condition-90 (seated with thighs horizontal; unrestricted range of movement) condition-45 (seated with thighs in 45°), and condition-0 (seated with hips maximally flexed; minimum range of movement). In condition-90, the trunk only actively contributed to the first push; for the remainder of the sprint, the trunk was held almost isometrically at 48.2° to the horizontal (range 42.1–56.4°). Similar patterns were observed for both condition-45 and condition-0. Compared with condition-90, participants in condition-0 had reduced capacity to accelerate of statistical (P < 0.05) and practical significance. These findings are an important initial step towards evidence-based decision making in classification. Future research should evaluate the individual and collective impact of other factors that affect the trunks contribution to wheelchair sports performance, including strapping, seating position, and impairments of trunk muscle power and coordination.

Trunk strength effect on track wheelchair start: implications for classification.

PURPOSE The T54 wheelchair racing class comprises athletes with normal arm muscle strength and trunk strength ranging from partial to normal. Paralympic sports classes should comprise athletes who have impairments that cause a comparable degree of activity limitation. On the basis of this criterion, the purpose of this study was to determine whether the T54 class is valid by assessing the strength of association between trunk strength and wheelchair acceleration. METHODS Participants were 10 male and 3 female international wheelchair track athletes with normal arm strength. Six were clinically assessed as having normal trunk strength, and seven had impaired trunk strength. Measures included isometric arm and trunk strength and distance covered at 1, 2, and 3 s in an explosive start from standstill on a regulation track, as well as on a custom-built ergometer with four times normal rolling resistance. RESULTS No significant differences were observed between male athletes with and without full trunk strength in distance covered after 1, 2, and 3 s. Correlations between isometric trunk strength and wheelchair track acceleration were nonsignificant and low (0.27-0.32), accounting for only 7%-10% of variance in performance. Correlations between trunk strength and distance pushed under high resistance were also nonsignificant, although values were almost double (r = 0.41-0.54), accounting for 18%-28% of the variance in performance. CONCLUSIONS These results provide evidence that impairment of trunk strength has minimal effect on wheelchair acceleration and indicate the T54 class is valid. Results do not infer that athletes with no trunk strength should compete with those who have partial or full trunk strength.

Taxonomic Theory and the ICF: Foundations for a Unified Disability Athletics Classification

Development of a unified classification system to replace four of the systems currently used in disability athletics (i.e., track and field) has been widely advocated. The definition and purpose of classification, underpinned by taxonomic principles and collectively endorsed by relevant disability sport organizations, have not been developed but are required for successful implementation of a unified system. It is posited that the International classification of functioning, disability, and health (ICF), published by the World Health Organization (2001), and current disability athletics systems are, fundamentally, classifications of the functioning and disability associated with health conditions and are highly interrelated. A rationale for basing a unified disability athletics system on ICF is established. Following taxonomic analysis of the current systems, the definition and purpose of a unified disability athletics classification are proposed and discussed. The proposed taxonomic framework and definitions have implications for other disability sport classification systems.

Impact of Enhanced Primary Care on equitable access to and economic efficiency of allied health services: a qualitative investigation

OBJECTIVE To evaluate new pathways to access allied health services introduced by the Enhanced Primary Care/Chronic Disease Management (EPC/CDM) initiative that may both increase or decrease equity to and efficiency in access. DESIGN A qualitative study consisting of semi-structured in-depth interviews with a purposively selected group of allied health practitioners. PARTICIPANTS AND SETTING. Allied health practitioners in private practice in Queensland, Australia, from physiotherapy, occupational therapy, speech pathology, and exercise physiology backgrounds (n = 15). MAIN OUTCOME MEASURES. Interviews focused upon several issues including how referrals are made under the EPC/CDM initiative and what happens for patients once their five allotted sessions are expended. RESULTS. The EPC/CDM initiative appeared to address two key barriers of access to allied health services - costs to patient of access and patient awareness of benefits. However, gap payments may still be deterring economically disadvantaged patients from attending. DISCUSSION The EPC/CDM initiative is increasing access to allied health services for people with chronic diseases. However, it is evident that this initiative may still not be meeting the needs of those most disadvantaged economically, and may lead to duplication of efforts by allied health practitioners when patients move between private and public health care sectors.