The document provides an overview of para sport and discusses considerations for training athletes with various disabilities. It defines key terms like para athlete and discusses the social-relational model of disability. It then examines specific disabilities like cerebral palsy, spinal cord injury, limb deficiency, visual impairment, and intellectual disability. For each disability, it discusses pathophysiology, special considerations, and training recommendations. Some overarching themes discussed are the high rates of injury and illness in para athletes, addressing strength asymmetries, monitoring medical conditions, and ensuring accessibility of training.

1. Page 1The University of Sydney
Understanding the Elite
Para Athlete:
Pathophysiology, programming and
training for athletes with a disability
Jennifer Fleeton
PhD Candidate, MExerSc (StrgthCondg), AEP
@Jflee_83

2. Page 2The University of Sydney
Para Sport - Overview

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= beside or alongside
= parallel to the Olympics; exists side by side
= all sport for athletes with a disability; not necessarily at an
elite level
= an athlete with a disability; not necessarily a Paralympian
(someone who has competed at the Paralympics)
Limb
deficiency
Intellectual
impairment
Short
stature
Low
vision
Muscle
strength
Hypertonia
Ataxia ROM
Athetosis
Loss of
limb
IPC Eligible Permanent
Impairments
Para-
Paralympics
Para sport
Para athlete

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A note on language & representation…
‘Overcoming’ disability
Inspiration objectification
Disability as a tragedy
“It isn’t a surprise when people with a
disability achieve things” – PWDA (2019)
“There isn’t a non-disabled person
hidden inside us” - PWDA (2019)
“We’re either seen as medicalized and helpless – or as super athletes.
Two extremes, nothing in the middle” – Saxton (2018)

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Influences on para athlete performance

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Why language matters
Additional physical, physiological, psychological, economic & social challenges
• 18.3% of Australians have a disability
• PWD are 15% less likely to participate in sport & physical activity
General barriers:
built & natural
environment
economic
equipment
regulations
Information
about options
psychological
knowledge
& education
attitudes & stigma
policies & resource
availability
coach prejudice
Athlete-specific barriers:
lack of empathy
in coach
low coach expectations
accessible training venues
funding
travel & accommodation
competition
equipment costs
bureaucracy
coach’s lack of disability- &
sport-specific knowledge
coach’s lack of disability- &
sport-specific knowledge
low coach expectations
lack of empathy
in coach
coach prejudice

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Social-relational model of disability
Emphasises subjective experience, acknowledges physiological aspects
– centralizes athletes’ experience in the disability sport context
Optimise your athlete’s disability sport experience by showing professionalism,
collaboration & consideration:
• Knowledge of disability types & sport-specific knowledge
• Learn from the athlete, adapt & problem-solve together
“The athlete is an expert in their own disability”
- Allan 2019
• Anticipate & address needs - remove barriers to participation
– Venue accessibility, travel & accommodation needs, access to equipment

8. Page 8The University of Sydney

9. Page 9The University of Sydney
London 2012
(n = 3565)
Sochi 2014
(n = 547)
Rio 2016
(n = 3657)
Pyeongchang
2018 (n = 567)
Injury IR
(95% CI)
12.7 (11.7 – 13.7) 26.5 (22.7 – 30.8) 10.0 (9.1 – 10.9) 20.9 (17.4 – 25.0)
Sport(s) with
highest IR
Football 5-a-side
(22.4)
Goalball (19.5)
Powerlifting (19.3)
Para alpine skiing
(43.8)
Para snowboard
(30.3)
Football 5-a-side (22.5)
Judo (15.5)
Football 7-a-side (15.3)
Para snowboard
(40.5)
Onset type
Acute traumatic
(52.2%)
Acute traumatic
(67.2%)
Acute traumatic
(51.8%)
Acute traumatic
(77.5%)
Most injured
body region
Shoulder (17.0%) Shoulder (24.1%) Shoulder (20.5%) Shoulder (27.4%)
Most injured
impairment
profile
- -
Limb deficiency
(32.0%)
Vision impairment
(20.0%)
SCI (18.4%)
Limb deficiency
(53.8%)
SCI (26.9%)
Illness IR
(95% CI)
13.2 (12.2-14.2) 18.7 (15.1 – 23.2) 10.0 (9.2 – 10.9) 12.8 (10.2 – 16.0)
Most common
illness type
Respiratory system
(27.4%)
Respiratory system
(30%)
Respiratory system
(32.7%)
Respiratory system
(32.2%)
IR = Incidence rate per 1000 athlete days; SCI = spinal cord injury

10. Page 10The University of Sydney
High Incidence of Injuries & Illnesses
• Higher injury & illness IR than Olympic athletes
• Most common injury type = acute traumatic injury
• Most injured area = shoulder
• Wheelchair users who use their UB for both locomotion and sport
• Athletes who compete in a wheelchair & use prostheses for ambulation
• Higher % upper limb injuries in wheelchair users, higher % lower limb injuries
in ambulant para athletes
• Athletes with limb deficiency at highest risk of injury
• Athletes with SCI at highest risk of illness

11. Page 11The University of Sydney
High Prevalence of Cardiovascular Disease
Pelliccia (2016)
• 12% CV abnormalities vs. 1-2% in Olympic athletes
• Paralympic Games participation doesn’t protect against higher CV risk for
individuals with a disability
• History + BP monitoring + 12-lead ECG detected 91% of incidents
12-lead ECG warranted for all para athletes??

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Pathophysiology, special considerations & training for
specific conditions

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Cerebral Palsy (CP)

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Cerebral Palsy (CP)
• Muscle weakness
• 43-90% lower than able bodied peers
• Decreased central activation & neural drive
• Agonist/ antagonist co-contraction
• Worse distally vs. proximally, concentric vs. eccentric, fast vs. slow movement velocity
• Impaired motor planning, MU recruitment & anticipation
• ↑ processing & reaction time, altered pacing strategies, variable movement patterns
• 2-3 x higher energy expenditure in walking ( fatigue)
• Lower peak energy reserve
• Walking at 50m/min = 53.5% VO2 peak, vs. 22.5% for typically developing children

15. Page 15The University of Sydney
Cerebral Palsy (CP)
Secondary & associated conditions
• Contractures & bone deformities
• Low BMD (from childhood)
• Functional loss with aging
• 52% experience deterioration of ambulation by age 37
• Premature sarcopenia
• Obesity/ normal weight obesity
•  body fat %,  muscle mass & BMD
• 2-3 x higher prevalence of CVD

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Movement
Disorder
Definition Special considerations
Spasticity
Ataxia
Athetosis
Dystonia
Fast eccentrics & rapid stretching contraindicated
Require spotting on all movements
• Likely to have contractures
• Static stretching unlikely to attenuate in adults
• Crouch gait common in diplegia
• ↑ flexion moment arm about knee
• ↑ risk knee injuries without major traumatic event
• Active ROM exercises & slow eccentrics may →
small +ve effect
Free weights may be contraindicated
Velocity-dependent resistance of a
muscle to stretch
Impaired muscle coordination →
poor balance, over/under-shooting
of movements, tremor
• Difficulty maintaining grip & moving limbs to a
target
• ↑ risk cervical spine stenosis → serious neurologic
injury
• Fluctuate in severity
• May vary with position, task, fatigue, emotional state
• Often occur with unfamiliar tasks
Involuntary sustained or intermittent
muscle contractions → twisting,
repetitive movements &/or postures
Slow, constantly changing,
contorting or writhing movements
• May have ‘wide-base gait’ pattern
• ↑ falls risk

17. Page 17The University of Sydney

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CP – Training Considerations
↑ power
co-contraction worsening spasticity
↑ strength differential response to
strength or power training
hypertrophy
pennation angle
selective activation muscle on/off timing
 ↑risk knee & ankle soft tissue injuries
 Know athlete’s seizure history & management plan
 Strength & power deficits vs. other para athletes
 Limb asymmetry ++
 Specific warm up: ↑MU excitability, ↑kinaesthetic awareness, ↑active ROM
 Screen for ↓BMD
 Potentially impaired transfer of motor skills between tasks
 Accommodate altered grip/ joint ROM
 Possible ↓ exercise tolerance, fatigue, chronic pain
 Potentially lower global physical literacy

19. Page 19The University of Sydney
Injury to the spinal cord from traumatic or nontraumatic causes (Dubon 2019)
Spinal Cord Injury (SCI)
https://asia-spinalinjury.org/wp-content/uploads/2016/02/International_Stds_Diagram_Worksheet.pdf
Effects on sensory & autonomic systems →
significant health challenges

20. Page 20The University of Sydney

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SCI – Autonomic Dysreflexia (AD)
Dubon (2019)

22. Page 22The University of Sydney
• SCI above T6
• Medical emergency → extreme hypertension, stroke &/or death if not
addressed
• AD considered with SBP:
• “Boosting” = deliberately inducing AD to enhance performance
• 10% ↑ middle distance wheelchair racing performance
• Banned by IPC
SCI – Autonomic Dysreflexia (AD)
>15mmHg above baselineChildren
15-20mmHg above baselineAdolescents
>20mmHg above baselineAdults
Treatment:
Immediate removal of trigger stimulus
Immediately cease exercise, loosen tight bindings, sit in upright position
Monitor BP, if no ↓BP will require pharmacological treatment & medical attention

23. Page 23The University of Sydney
Lesions T6 & above →
Cardiac output & VO2max impacted
Sympathetic cardiac innervation
LB muscular venous pump
HRmax 110-130 bpm
↓HRR
↓stroke volume
SCI – Autonomic & Sensory Effects
Williams (2018)

24. Page 24The University of Sydney
• Neurogenic bladder
• ↑ risk bladder infections, urinary stones & urinary tract obstruction
• Cause pain, pyrexia, ↑ muscle spasticity, AD
• Requires plan for travel
• Neurogenic bowel
• Important to keep regular & effective bowel program to avoid infection
• Youth athletes may not be independent with bowel program
• Requires plan for travel
SCI – Autonomic & Sensory Effects
Griggs(2019)
• Impaired thermoregulation
• Inability to sweat or shiver below lesion level
• Impaired blood flow regulation
• Use cooling strategies even in ambient
temperature
• Don’t rely on athlete-reported skin temperature
sensation

25. Page 25The University of Sydney
• Pressure sores
• Repetitive movements, long-haul travel
• Can → serious deep infections, AD
• Early signs & symptoms = persistent redness, hardening of skin, raised areas
• Immediately relieve area of all pressure until healed
• Low BMD (below level of lesion)
• ↑ fracture risk from even minor injuries, ↓ sensation of fracture
• Spasticity may or may not be present
• 4x higher risk of depression
• Potential mental health impacts of traumatic injury
• 65-85% people with SCI report neuropathic pain
• 50-70% report upper limb musculoskeletal pain
SCI – Sensory & Autonomic Effects

26. Page 26The University of Sydney
SCI – Training Considerations
 Aim to optimize ‘wheelchair-athlete interface’
 Know athlete’s baseline BP, monitor regularly for AD
 VO2max, anaerobic peak power & strength inversely related to lesion
level & injury completeness
 ↑ risk shoulder injuries
o Rehab program for all wheelchair users
o Regular wheelchair maintenance to ↓ rolling resistance
o Consider athlete’s daily ambulation requirements to ↓ overload & optimize
load prescription
 SCI above T6 HRmax = 100-140bpm
 Cooling strategies even in ambient temperatures
 Extended warm-up & cooldown to prevent postexercise hypotension
 ↑ risk fractures
 Minimize transitions between wheelchair & resistance machines
 Travel considerations for skin, neurogenic bladder, neurogenic bowel

27. Page 27The University of Sydney
Absence of bone or joints resulting from:
• congenital limb deficiency
• amputation following traumatic injury or vascular/ bone pathology
• Potentially reduced blood lactate clearance potential
• Need to consider for physiological profiling
• H+ buffering strategies may be useful
Limb Deficiency
↓ body mass + retained
high work potential
remaining muscle mass
↓ clearance
potential
↑ blood lactate @ given
intensity vs non-disabled
athletes

28. Page 28The University of Sydney
• CV response & adaptation to training maintained in unaffected limbs
• Depends on primary condition
• Highest injury risk of all para athlete groups
• Residual limb care vital to maintain athlete robustness & training availability
• Abrasions, pressure sores, blisters, bacterial/ fungal infections at socket
interface
• Potential for impaired thermoregulation for athletes with 2 or more
amputations
• Altered ratio skin surface area to body volume
• ↑ sweat response
• ↑EE with prosthetic use
• Preserved trunk function
• ↑ wheelchair propulsion ability vs. athletes with SCI
Limb Deficiency
→ ↑fatiguability

29. Page 29The University of Sydney
• Travel considerations
• Consider required walking distances e.g. around athlete village – may increase
loading & risk skin breakdown
• Residual limb oedema risk if prosthesis removed in-flight
• Skin irritation risk if prosthesis is worn
Limb Deficiency
Affected limb Special Considerations
Upper limb amputation
Trans-tibial amputation
Trans-femoral amputation
Aim to address strength asymmetries in hip flexion,
extension & rotation
Aim to address strength asymmetries, emphasise scapular
control, maintain thoracic ROM
• Method of attachment to load
• ↑ likelihood scoliosis with unilateral amputation
• Similar long & high jump kinematics to non-disabled
athletes
• Altered Q & HS agonist/antagonist actions
• Altered gait & jumping kinematics
• Altered orientation of spine & pelvis

30. Page 30The University of Sydney
Limb Deficiency – Training Considerations
 Can perform most traditional resistance & aerobic exercises
o Altered balance & leverage with resistance activities
o Consider how load is applied to residual limb & prosthetic
 Address strength asymmetries
 ↑ risk shoulder injuries for wheelchair athletes
o Rehab program for all wheelchair users
o Regular wheelchair maintenance to ↓ rolling resistance
 Monitor residual limb condition
o Use alternative training methods during high loading periods
 Dehydration due to ↑ sweat response
 Travel considerations for residual limb skin care
 Consider energy cost of ambulation during competition period

31. Page 31The University of Sydney
Damage to one or more components of the visual system
o Athletes may have low vision or no vision at all
• ↑ risk injury in football 5-a-side
• Collision & foul-play related acute traumatic injuries
• ↑ risk tripping or collisions in unfamiliar environments
• Practical difficulties with self-monitoring
• Difficult to monitor urine colour & volume
• Access to training programs provided by coaches
• Balance may be impacted
Visual Impairment

32. Page 32The University of Sydney
Visual Impairment – Training Considerations
 Untidy weights room → significant trip hazzards
 Consider how training programs are presented
o Font size
o Readability of digital files for text-to-speech software users
 Ensure clear landing area for plyometrics & bounding
o Use hurdles & boxes with caution
 Alternatives to urine self-monitoring for hydration status
 Don’t move an athlete’s cane without permission
 Identify yourself & others when approaching an athlete with visual impairment
o Introduce new people as they approach
o Don’t leave without saying you’re leaving

33. Page 33The University of Sydney
Intellectual Disability (ID)
o Onset before age 18
o Significant impairment of adaptive & intellectual functioning
• Varied aetiology, often unknown
• Commonly co-occurring with CP, epilepsy, autism, sensory & visual impairments
• Impaired processing speed, visual perception, memory & learning, visual-
motor abilities & executive functioning
• Impacts pacing, reaction time, adjustments e.g. stride length to execute successful
long jump take-off
Neurodevelopmental Disabilities
 Use specific, concrete language without being too simplistic
 May benefit from internal focus of attention, blocked practice, extended
time to learn techniques
 Treat adults with ID as adults
 Allow extra time for responses in conversation
 Unexpected changes in training environment or routine may induce stress
 Accommodate difficulties with reading & writing
 Medical considerations of underlying condition (if known)

34. Page 34The University of Sydney
Autism
o Difficulties with adaptive functioning, executive function, social communication
• Not an IPC eligible impairment but often co-occurring with CP & ID
• High levels of anxiety, altered sensory processing
• Identity-first language
• Atypical language acquisition & use
• May speak formally, use atypical pitch, volume or rhythm, echolalia or be non-verbal
• May have difficulty understanding nuance & figurative language
• High prevalence sleep disorders
Neurodevelopmental Disabilities
 Use explicit instructions, avoid figurative speech
o Explicitly outline facility rules & expectations
 Determine the athlete’s motivators
 Accommodate athlete’s sensory sensitivities
o Music volume, lights, smells, crowded training facilities
 Establish preferred communication methods
 Allow extra time for responses in conversation
 Unexpected changes in training environment or routine may induce stress

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Optimizing performance for para athletes

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CV risk
factors
Family Hx
Surgeries
Medications
Co-occurring
conditions
MSK Hx
Seizure risk &
action plan
Bladder &
bowel function
Thermoregulation
Movement
disorders
Spasticity
Dystonia
Athetosis
Ataxia
BMD/ fracture Hx
Refer to medical
practitioner
Written & verbal
communication
Access/ mobility
requirements
Travel
requirements
Assistance with
transfers
Grip/ loading
methods
Environmental
accommodations
Method(s) of
ambulation
Ambulation
Competition
Pain
profile
Interactions &
Instructions
Adaptations to
cues, program
delivery etc
Training Hx
Allied health
What did/didn’t
work? Why?
Current/ past
major illness
Condition-
specific risks
Stress
SleepNutrition
BP
12-lead ECG
Skin health
Physiological
Initial
Assessment
Pre-ex
screening
Physical
assessment
Full clinical
Hx
Current
medical Hx
Condition
profile
Cognitive
ability & skills
Wellbeing
Illness Hx
Ex Hx
Condition-
specific risks/
considerations
Recent changes in
neurologic function
Required
accommodations
‘Athlete-
equipment
interface’

38. Page 38The University of Sydney
Sport needs
analysis
Athlete-equipment
interface
Physiologic
Injury risks
Athlete/ coach
goals
Performance
goals
Short
Medium
Long
Physiologic
goals
Strength
Power
Speed
Metabolic
Rehabilitation
needs
Condition-
specific
Current/ past
injuries
Prioritizing Training Demands
Impacting performance
or posing risk?
Yes
No
Address within
main program
Address within warm
up/ recovery protocol
#1 limiting factor right now?
Likelihood to respond?
Athlete-specific contraindications/
considerations
The athlete is the expert on their body

39. Page 39The University of Sydney
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Curr Dev Disord Rep. 6:45-56
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Palgrave Handbook of Paralympic Studies. https://doi.org/10.1057/978-1-137-47901-3_19
• Dubon, M. et. al. (2019). Youth Para and Adaptive Sports Medicine. Curr Phys Med Rehabil Rep. 7: 104-115
• Griggs, K. et al. (2019). Infographic. Thermoregulatory impairment in athletes with a spinal cord injury. Br J
Sports Med. 53:1305-1306
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References