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Introduction The Female Athlete Triad (Triad) is a syndrome describing three interrelated conditions: low energy availability (LEA), menstrual dysfunction, and low bone mineral density (BMD). Relative Energy Deficiency in Sport (RED-S) expands the Triad to include multiple physiologic consequences of LEA in both sexes. The purpose of this study is to determine the prevalence of factors associated with the Triad/RED-S in an elite para athlete population. Methods Athletes were U.S. elite para athletes training to qualify for the 2016 or the 2018 Paralympic Games. Participants completed an online questionnaire characterizing nutrition, menstrual status (in females), bone health, and awareness of the Triad/RED-S. Results The athletes were 260 elite para athletes (150 male, 110 female). While few reported prior eating disorder (3.1%), 32.4% had elevated Eating Disorder Examination Questionnaire (EDE-Q) pathologic behavior subscale scores. Most athletes (95 male, 65 female) were attempting to change their body composition or weight to improve performance. Forty-four percent of premenopausal females had oligomenorrhea/amenorrhea. Bone stress injury was reported in 9.2% of athletes; of these, 54.5% (n = 12) had low BMD. Less than 10% of athletes reported awareness of the Triad/RED-S. Conclusions Factors associated with the Triad/RED-S are present in an elite para athlete population, regardless of sex or sport type. Awareness of the Triad/RED-S in para athletes is low. The consequences of LEA in para athlete populations are poorly understood. However, the high prevalence of factors observed suggests value in advancing screening tools and education efforts to optimize health in this population.

Over the past half-century, the evolution of Paralympic sport has exponentially increased opportunities for elite sports competition for athletes with disabilities while revolutionising conceptual frameworks about sport and disability. Despite the rapid growth of the Paralympic Movement, women and athletes with high support needs (AHSN) have remained underrepresented. Both female athletes with disabilities and AHSN have historically faced distinct barriers to sports participation and underrepresentation at elite levels of competition in Paralympic sport. Nonetheless, social and cultural trends promoting inclusion, such as increased visibility and grass-roots opportunities for sports participation, have contributed to an overall increase in participation by athletes in both groups. New areas of Paralympic sports research are needed to inform future strategies that maximise inclusion while ensuring elite sports competition.

In 2014, the IOC published a consensus statement entitled ‘Beyond the Female Athlete Triad: Relative Energy Deficiency in Sport (RED-S)’. The syndrome of RED-S refers to ‘impaired physiological functioning caused by relative energy deficiency and includes, but is not limited to, impairments of metabolic rate, menstrual function, bone health, immunity, protein synthesis and cardiovascular health’. The aetiological factor of this syndrome is low energy availability (LEA).1 The publication of the RED-S consensus statement stimulated activity in the field of Female Athlete Triad science, including some initial controversy2 3 followed by numerous scientific publications addressing: 1. The health parameters identified in the RED-S conceptual model (figure 1).1 4 2. Relative energy deficiency in male athletes. 3. The measurement of LEA. 4. The performance parameters identified in the RED-S conceptual model (figure 2).1 4 The IOC RED-S consensus authors have reconvened to provide an update summary of the interim scientific progress in the field of relative energy deficiency with the ultimate goal of stimulating advances in RED-S awareness, clinical application and scientific research to address current gaps in knowledge. Figure 1 Health consequences of Relative Energy Deficiency in Sport (RED-S) showing an expanded concept of the Female Athlete Triad to acknowledge a wider range of outcomes and the application to male athletes (*Psychological consequences can either precede RED-S or be the result of RED-S).1 4 Figure 2 Potential Performance consequences of Relative Energy Deficiency in Sport (*Aerobic and anerobic performance).1 4 ### Low energy availability LEA, which underpins the concept of RED-S, is a mismatch between an athlete’s energy intake (diet) and the energy expended in exercise, leaving inadequate energy to support the functions required by the body to maintain optimal health and performance. Operationally, energy availability (EA) is defined as: ![Formula][1] where exercise energy expenditure (EEE) is calculated as the additional energy expended above that of … [1]: /embed/mml-math-1.gif

Results of the Paralympic Injury and Illness Surveillance Study noted an unusually high injury incidence rate (IR) in the sport of Para alpine skiing at the 2014 Sochi Paralympic Games (IR 48.3, a sixfold increase in acute injuries in comparison to the Vancouver 2010 Paralympic Games).1–3 There were likely several associated factors. Some were clearly modifiable such as the course design, number of training runs permitted on the course and the command and control structure between the technical and medical staff. Additionally, Paralympic officials recognised that careful monitoring of weather data and timely management of snow production, taking advantage of modern technology, had the potential to reduce injury risk. Thus, for the 2018 PyeongChang Paralympic Winter Games (the Games), the International Paralympic Committee (IPC) Medical Committee, in collaboration with the World Para Alpine Skiing (WPAS) sport technical staff, implemented a series of changes following Professor Willem van Mechelen’s ‘Sequence of (Injury) Prevention’ model4: The Paralympic Injury and Illness Surveillance Study carried out at the Sochi 2014 Paralympic Games demonstrated a dramatic …

Hip soft tissue injuries can cause significant functional morbidity. Given the complex anatomy of the hip and lumbopelvic region, these entities may be difficult to differentiate and diagnose due to commonly overlapping pain patterns. This chapter describes the most common hip-related soft tissue disorders, categorizing each diagnosis as those that present as anterior, lateral, and posterior hip pain in order to best aid clinicians in considering a differential and expeditiously initiating the correct diagnosis and treatment approach. The majority of hipsoft tissue injuries can improve, or resolve, with appropriate rehabilitation and nonoperative treatment strategies.

The sport of Para alpine skiing at the Sochi 2014 Paralympic Winter Games has been under the spotlight as having the highest injury incidence rate (IR) compared with other sports on the programme,1 and also compared with alpine skiing at any previous Paralympic Winter Games.2 3 A secondary analysis of the Paralympic Injury and Illness Survey for the Sochi Games has allowed for a more detailed reporting of injury mechanism. In Sochi, a total of 175 athletes (131 male, 44 female) participated in the Para alpine skiing competitions. This comprised 65 seated athletes and 110 standing athletes. The overall injury IR in alpine skiing was 48.3 (95% CI 40.1 to 56.4) injuries per 1000 athlete-days, while the overall injury proportion was 30.9 (95% CI 24.0 to 37.7) injuries per 100 athletes. The comparative injury IR in the different athlete categories is shown in figure 1. Figure 1 Injury incidence rate (IR) in Para alpine skiing at the Sochi 2014 Paralympic Winter Games. Upon further analysis of the data, …

Background The epidemiology of injury in Paralympic football has received little attention. A study of all sports at the London 2012 Paralympic Games identified football 5-a-side as the sport with the highest injury rate, meriting further detailed analysis, which may facilitate the development of strategies to prevent injuries. Objective To examine the injury rates and risk factors associated with injury in Paralympic football. Design Secondary analysis of a prospective cohort study of injuries to football 5-a-side and football 7-a-side athletes. Setting London 2012 Paralympic Games. Participants Participants included 70 football 5-a-side athletes and 96 football 7-a-side athletes. Athletes from all but one country chose to participate in this study. Methods The Paralympic Injury and Illness Surveillance System was used to track injuries during the Games, with data entered by medical staff. Main Outcome Measurements Injury incidence rate (IR) and injury incidence proportion (IP). Results The overall IR for football 5-a-side was 22.4 injuries/1000 athlete-days (95% confidence interval [CI], 14.1-33.8) with an IP of 31.4 injuries per 100 athletes (95% CI, 20.9-43.6). In 5-a-side competition, 62.5% of injuries were associated with foul play. The overall IR for football 7-a-side was 10.4 injuries/1000 athlete-days (95% CI, 5.4-15.5), with an IP of 14.6 injuries per 100 athletes (95% CI, 7.5-21.6). The most commonly injured body region in both sports was the lower extremity. Conclusions To our knowledge, this study is the first to examine IR and risk factors associated with injury in Paralympic football. Future studies are needed to determine mechanisms of injury and independent risk factors for injury, thus informing prevention strategies.

Sport injury epidemiology has received increased recognition as a field of sport medicine research that can improve the health and safety of athletes. Injuries among Paralympic powerlifters have not previously been systematically studied. The purpose of this prospective cohort study was to characterize injuries among Paralympic powerlifters. Athletes competing in the sport of powerlifting were followed over the 7-day competition period of the 2012 London Paralympic Games. The main outcome measurements were injury incidence rate (IR; number of injuries per 1000 athlete-days) and injury incidence proportion (IP; injuries per 100 athletes). A total of 38 injuries among 163 powerlifters were documented. The overall IR was 33.3 injuries/1000 athlete-days (95% CI 24.0-42.6) and the overall IP was 23.3 injuries per 100 athletes (95% CI 16.8-29.8). The majority of injuries were chronic overuse injuries (61%). The most commonly injured anatomical region was the shoulder/clavicle (32% of all injuries), followed by the chest (13%) and elbow (13%). The information obtained in this study opens the door for future study into the mechanisms and details of injuries into powerlifters with physical impairments.

I have asked Gayle Spill, MD, to guest edit this Ethical Legal column. Dr Spill is a physiatrist and clinical ethicist who has been in practice for more than 20 years and has written on topics including cancer prognosis disclosure and quality of life considerations. She and I invited 3 experts to respond to a general query about the ethical and legal issues surrounding the team physician. Our first columnist, Cheri Blauwet, MD, is a physiatrist at Spaulding Rehabilitation Hospital and the Brigham and Women’s Hospital in Boston, a Paralympic gold medallist, and chairperson of the Medical Committee of the International Paralympic Committee. Our second

Increased participation and expanded public interest in the Paralympic Games underline the growing importance of competitive sports opportunities for individuals with disabilities. Injury surveillance is increasingly recognized as a key element of sports medicine research, and recent work has suggested that rates of injury, anatomic location of injury, and associated illness may in fact differ in athletes with disabilities. A greater understanding of the patterns of injury and illness for athletes with disabilities has important clinical implications for rehabilitation and sports medicine physicians. This review summarizes commonly observed musculoskeletal injuries that affect athletes with disabilities, including athletes using sports wheelchairs for competition, athletes with amputations, athletes with cerebral palsy, and athletes with visual impairment. Medical issues that may affect athletes with disabilities include autonomic dysreflexia, complications of neurogenic bowel and bladder, impaired thermoregulation, and skin breakdown. As a growing number of athletes with disabilities participate in sports activities, physicians must develop an increased understanding and expertise in treating and preventing injuries in these athletes.

ObjectiveTo describe the epidemiology of illness at the Rio 2016 Summer Paralympic Games.MethodsA total of 3657 athletes from 78 countries, representing 83.5% of all athletes at the Games, were monitored on the web-based injury and illness surveillance system (WEB-IISS) over 51 198 athlete days during the Rio 2016 Summer Paralympic Games. Illness data were obtained daily from teams with their own medical support through the WEB-IISS electronic data capturing systems.ResultsThe total number of illnesses was 511, with an illness incidence rate (IR) of 10.0 per 1000 athlete days (12.4%). The highest IRs were reported for wheelchair fencing (14.9), para swimming (12.6) and wheelchair basketball (12.5) (pConclusion(1) The rate of illness was lower than that reported for the London 2012 Summer Paralympic Games; (2) the sports with the highest risk were wheelchair fencing, para swimming and wheelchair basketball; (3) female and older athletes (35–75 years) were at increased risk of illness; and (4) the respiratory system, skin and subcutaneous system and digestive system were most affected by illness. These results allow for comparison at future Games.

Exercise provides a well-recognized foundation for health maintenance and chronic disease prevention for all individuals, and those with disabilities can equally benefit. Still, many health and physical activity disparities exist between individuals with disabilities and the general population. Despite the higher prevalence of chronic, noncommunicable disease in people with disabilities such as obesity, diabetes mellitus, and coronary artery disease, studies reveal that this population is less likely to engage in the essential physical activity to help decrease health risks. Additionally, participation in health and wellness promotion programs that could mitigate these risks is negatively impacted by various environmental, socioeconomic, and interpersonal barriers that disproportionately affect the disability community. Government regulations, such as Section 504 of the Rehabilitation Act, Americans with Disabilities Act, and the Individuals with Disabilities Education Act, protect the basic rights of individuals with disabilities and serve to facilitate participation in physical activity and sports participation. Meanwhile, many educational and public health policies exist to promote the inclusion of people with disabilities into all mainstream programs. Continued efforts are necessary to expand these opportunities for individuals with disabilities from the developmental to elite levels of sport.

ObjectivesTo describe the incidence of injury in the precompetition and competition periods of the Rio 2016 Summer Paralympic Games.MethodsA total of 3657 athletes from 78 countries, representing 83.4% of all athletes at the Games, were monitored on the web-based injury and illness surveillance system over 51 198 athlete days during the Rio 2016 Summer Paralympic Games. Injury data were obtained daily from teams with their own medical support.ResultsA total of 510 injuries were reported during the 14-day Games period, with an injury incidence rate (IR) of 10.0 injuries per 1000 athlete days (12.1% of all athletes surveyed). The highest IRs were reported for football 5-a-side (22.5), judo (15.5) and football 7-a-side (15.3) compared with other sports (pConclusionThe data from this study indicate that (1) IRs were lower than those reported for the London 2012 Summer Paralympic Games, (2) the sports of football 5-a-side, judo and football 7-a-side were independent risk factors for injury, (3) precompetition injuries had a higher IR than competition period injuries, (4) injuries to the shoulder were the most common. These results would allow for comparative data to be collected at future editions of the Games and can be used to inform injury prevention programmes.

It is well known that individuals with disabilities, constituting 15% to 20% of the adult population, experience a disproportionate risk of cardiometabolic disease and are more likely to live sedentary lifestyles when compared with their able-bodied peers. Although many complex factors likely lead to these disparities, targeted exercise programs can be influential in improving the health outcomes of this population. Additionally, it is important to keep several factors in mind when tailoring the exercise prescription for individuals with varied types of disability, given unique factors related to medical history, mobility, and community barriers. By safely engaging individuals with disabilities in exercise programs, clinicians can promote inclusion while making a significant contribution to health outcomes, ensuring that the principles of "Exercise is Medicine" are accessible to individuals of all abilities.

Membership in medical societies is associated with a number of benefits to members that may include professional education, opportunities to present research, scientific and/or leadership training, networking, and others. In this perspective article, the authors address the value that medical specialty society membership and inclusion have in the development of an academic physician's career and how underrepresentation of women may pose barriers to their career advancement. Because society membership itself is not likely sufficient to support the advancement of academic physicians, this report focuses on one key component of advancement that also can be used as a measure of inclusion in society activities—the representation of women physicians among recipients of recognition awards. Previous reports demonstrated underrepresentation of women physicians among recognition award recipients from 2 physical medicine and rehabilitation specialty organizations, including examples of zero or near-zero results. This report investigated whether zero or near-zero representation of women physicians among recognition award recipients from medical specialty societies extended beyond the field of physical medicine and rehabilitation. Examples of the underrepresentation of women physicians, as compared with their presence in the respective field, was found across a range of additional specialties, including dermatology, neurology, anesthesiology, orthopedic surgery, head and neck surgery, and plastic surgery. The authors propose a call for action across the entire spectrum of medical specialty societies to: (1) examine gender diversity and inclusion data through the lens of the organization's mission, values, and culture; (2) transparently report the results to members and other stakeholders including medical schools and academic medical centers; (3) investigate potential causes of less than proportionate representation of women; (4) implement strategies designed to improve inclusion; (5) track outcomes as a means to measure progress and inform future strategies; and (6) publish the results to engage community members in conversation about the equitable representation of women.

Low energy availability, functional hypothalamic amenorrhea, and low bone mineral density are three interrelated conditions described in athletic women. Although described as the female athlete triad (Triad), males experience similar health concerns. The literature suggests that individuals with a disability may experience altered physiology related to these three conditions when compared with the able-bodied population. The goal of this review is to describe the unique implications of low energy availability, low bone mineral density, and, in females, menstrual dysfunction in individuals with a disability and their potential impact on the para athlete population. A literature review was performed linking search terms related to the three conditions with six disability categories that are most represented in para sport. Few articles were found that directly pertained to athletes, therefore, the review additionally characterizes literature found in a non-athlete population. Review of the available literature in athletes suggests that both male and female athletes with spinal cord injury demonstrate risk factors for low energy availability. Bone mineral density may also show improvements for wheelchair athletes or athletes with hemiplegic cerebral palsy when compared with a disabled non-athlete population. However, the prevalence of the three conditions and implications on the health of para athletes is largely unknown and represents a key gap in the sports medicine literature. As participation in para sport continues to increase, further research is needed to understand the impact of these three interrelated health concerns for athletes with a disability, accompanied by educational initiatives targeting athletes, coaches, and health professionals.

It is well known that athletes with spinal cord injury (SCI) may experience altered autonomic physiology that impacts their exercise capacity and sports performance. This is particularly relevant given the ever-increasing number of individuals with SCI who are actively engaged in sports at all levels, from community-based adaptive sports to elite Paralympic competitions. As such, the purpose of this article is to review the present literature regarding the implications of altered autonomic control on the safety and performance of athletes with SCI. A particular emphasis will be placed on the autonomic aspects of cardiovascular and thermoregulatory control in the athlete population, as well as the implications of autonomic dysreflexia in enhancing sports performance. Further research is needed to understand the autonomic factors that influence athletes with SCI in order to ensure optimal and safe sports competition. Additionally, this information is crucially relevant to the coaches, sports administrators, and team medical staff who work closely with athletes with SCI.

Background In this study we describe (1) the implementation of a novel web-based injury and illness surveillance system (WEB-IISS) for use by a team of physicians at multisport events and (2) the incidence and characteristics of injuries and illness in athletes during the London 2012 Paralympic Games. Methods Overall, 3565 athletes from 160 of the 164 participating countries were followed daily over a 14-day period, consisting of a precompetition period (3 days), and a competition period (11 days) (49 910 athletedays). Daily injury and illness data were obtained from teams with their own medical support (78 teams, 3329 athletes) via the WEB-IISS, and without their own medical support through the London Organising Committee of the Olympic Games and Paralympic Games database (82 teams and 236 athletes). Results There were no differences between incidence rates (IR) of injury and illness, or between the precompetition and competition periods. The IR of injury during the competition period was 12.1/1000 athlete-days, with an incidence proportion (IP) of 11.6% (95% CI 11.0% to 13.3%). Upper limb injuries (35%), particularly of the shoulder (17%) were most common. The IR of illness during the competition period was 12.8/1000 athlete-days (95% CI 12.18 to 1421), with an IP of 10.2%. The IP was highest in the respiratory system (27.4%), skin (18.3%) and the gastrointestinal (14.5%) systems. Conclusions During the competition period, the IR and IP of illness and injury at the Games were similar and comparable to the observed rates in other elite competitions. In Paralympic athletes, the IP of upper limb injuries is higher than that of lower limb injuries and non-respiratory illnesses are more common.

Background The incidence and factors associated with illness in Paralympic athletes have not been documented. Aim To determine the factors associated with illness in athletes participating in the London 2012 Paralympic Games. Methods A cohort of 3565 athletes from 160 of the 164 participating countries in the London 2012 Paralympic Games were followed over a 14-day period (precompetition period=3 days, competition period=11 days; 49 910 athlete-days). Daily illness data were obtained from (1) teams with their own medical support who completed a daily illness log (78 teams, 3329 athletes) on a novel web-based system and (2) teams without their own medical support through the local organising committee database (82 teams, 236 athletes). Illness information from all athletes included age, gender, type of sport and the main system affected. Main outcome measurement Incidence rate (IR) of illness (illness per 1000 athlete-days) and factors associated with IR (time period, gender, age and sport). Results The IR of illness was 13.2 (95% CI 12.2 to 14.2). The highest IR of illness was in the respiratory system, followed by the skin, digestive, nervous and genitourinary systems. The IR in the precompetition period was similar to that in the competition period, but the IR was significantly higher in athletics compared with other sports. Age and gender were not independent predictors of illness. Conclusions Illness is common in Paralympic athletes and the main factor associated with higher IR of illness was the type of sport (athletics).

Background The characteristics and incidence of injuries at the Summer Paralympic Games have not previously been reported. A better understanding of injuries improves the medical care of athletes and informs future injury prevention strategies. Objective The objective of this prospective cohort study was to characterise the incidence and nature of injuries during the London 2012 Summer Paralympic Games. Methods Injury information was obtained from two databases. One database was populated from medical encounter forms completed by providers at the time of assessment in one of the medical stations operated by the Organising Committee. The second database was populated daily with information provided by team medical personnel who completed a comprehensive, web-based injury survey. Results The overall injury incidence rate was 12.7 injuries/1000 athlete-days. Injury rates were similar in male and female athletes. The precompetition injury rates in women were higher than those in the competition period. Higher injury rates were found in older athletes and certain sports such as football 5-a-side (22.4 injuries/1000 athlete-days). Overall, 51.5% of injuries were new onset acute traumatic injuries. The most commonly injured region (percentage of all injuries) was the shoulder (17.7%), followed by the wrist/hand (11.4%), elbow (8.8%) and knee (7.9%). Conclusions This is the largest and most comprehensive epidemiological report examining injuries in Paralympic athletes. Injury rates differ according to age and sport. Upper limb injuries are common. The knowledge gained from this study will inform future injury surveillance studies and the development of prevention strategies in Paralympic sport. The Epidemiology of Injuries at the London 2012 Paralympic Games.

Medical specialty societies are important resources for physicians in advancing their careers. There is a gap in the literature regarding gender disparities within these societies. This study assesses one area where disparities may exist: recognition awards.To determine whether female physicians are underrepresented among recognition award recipients by the American Academy of Physical Medicine and Rehabilitation (AAPMR).Surveillance study.A published online list of national award recipients from the AAPMR was analyzed. Forty-eight years of data were included, as the list contained all major recognition award recipients from 1968 to 2015. All awards that were given exclusively to physicians were included. There were eight award categories listed online; seven met this criterion, with a total of 264 individual awards presented. One award category was excluded because it focused on distinguished public service and included both physician and nonphysician (eg, public official) recipients. Awards that were not published online were also excluded.Total awards given to female versus male physicians from 1968 to 2015, with awards given over the past decade (2006-2015) assessed independently. Lectureships were also analyzed as a set. For awards given to groups of physician recipients, analysis included gender composition of the group (eg, male only versus female only versus mixed-gender physician groups). To assess the proportion of female versus male physiatrists over time, physician gender and specialty data from 3 sources were used: the American Medical Association (AMA), the Association of American Medical Colleges (AAMC), and the AAPMR.Over the past 48 years, the AAPMR presented 264 recognition awards to physicians. Award recipients were overwhelmingly male (n = 222; 84.1%). Females received 15.9% (n = 42) of the total awards, although there was an upward trend in female physician recipients to 26.8% (n = 26) from 2006 to 2015. Lectureships were given to 8 female physicians (n = 8 of 77, 10.4%). These results were lower than the proportion of female physicians in the field of physiatry (35% in 2013). Female physicians were more likely to receive awards if they were part of a group and less likely to be recognized if the award was given to only 1 recipient each year or involved a lectureship with a speaking opportunity at a national meeting.To our knowledge, this is the first study in medicine to assess whether female physicians are underrepresented among recipients of recognition awards presented by a national medical society. For nearly half a century, female physicians have been underrepresented in awards presented by the AAPMR. Although it is encouraging that the proportion of female physicians receiving awards is increasing, further research is needed to understand why underrepresentation remains.Not applicable.

Today, there is an increased realization that engaging with Paralympic athletes offers the chance for healthcare professionals to work at the intersection of rehabilitation with sports and exercise medicine. The study of both injury and illness epidemiology in Paralympic sport is important, as findings may assist in the formulation of prevention strategies. A model for the systematic development of sports injury-prevention strategies has been developed and is used by the International Paralympic Committee (IPC) Medical Committee. Cardiac screening is recommended to start at the beginning of competitive athletic activity, usually between the ages of 12 and 14 years. There is a need for a detailed epidemiological data on head injuries and concussion in Paralympic sports, as most of the injury reports are anecdotal. When treating athletes, clinicians must closely consider the interaction between a medication's pharmacokinetics and the athlete's physiology. The chapter also discusses the effects of travel and sports nutrition for Paralympic athletes. (Less)

Background Although community-based adaptive sports have become a popular means of rehabilitation for individuals with disabilities, little is known regarding the factors that lead to sustained participation. Objective To determine the demographic, environmental, disability-related, and functional factors associated with sustained participation in a community-based adaptive sports program. Design Retrospective cohort study. Setting Community-based adaptive sports program. Participants Adults with mobility-related disabilities. Methods Data were collected from registration forms and participation logs. Participants were described as "sustainers" if they attended ≥2 sessions, or as "nonsustainers" if they attended 0 or 1 session. We examined the associations between sustained participation and demographic, environmental, disability-related, and functional factors in bivariate and multivariable analyses. Main Outcome Measurement Sustained participation in the adaptive sports program. Results Of the 134 participants, 78 (58%) were sustainers and 56 (42%) were nonsustainers. In multivariable analyses, participants who ambulated independently had lower odds of being sustainers (odds ratio [OR] = 0.33, 95% confidence interval [CI] = 0.11, 0.96), and those who used an ambulatory assistive device had twice the odds of being sustainers (OR = 2.0, 95% CI=0.65, 6.2) compared to those who used a manual wheelchair. Moreover, participants who lived within 5.3 miles of the program site (OR = 3.8, 95% CI=1.1, 13.0) and those who lived between 5.3 and 24.4 miles from the program site (OR = 2.8, 95% CI=1.0, 7.7) had significantly higher odds of sustained participation than those who lived more than 24.4 miles from the program site. Conclusion Sustained participation in community-based adaptive sports is associated with living closer to the program site and the presence of a moderate level of functional impairment. These findings suggest that programs might consider increasing the number of satellite sites and expanding offerings for individuals with mild or more significant mobility-related disabilities to effectively increase program participation. Level of Evidence II

Despite the well-recognised benefits of sport, there are also negative influences on athlete health, well-being and integrity caused by non-accidental violence through harassment and abuse. All athletes have a right to engage in ‘safe sport’, defined as an athletic environment that is respectful, equitable and free from all forms of non-accidental violence to athletes. Yet, these issues represent a blind spot for many sport organisations through fear of reputational damage, ignorance, silence or collusion. This consensus statement extends the 2007 IOC Consensus Statement on Sexual Harassment and Abuse in Sport, presenting additional evidence of several other types of harassment and abuse—psychological, physical and neglect. All ages and types of athletes are susceptible to these problems but science confirms that elite, disabled, child and lesbian/gay/bisexual/trans-sexual (LGBT) athletes are at highest risk, that psychological abuse is at the core of all other forms and that athletes can also be perpetrators. Harassment and abuse arise from prejudices expressed through power differences. Perpetrators use a range of interpersonal mechanisms including contact, non-contact/verbal, cyber-based, negligence, bullying and hazing. Attention is paid to the particular risks facing child athletes, athletes with a disability and LGBT athletes. Impacts on the individual athlete and the organisation are discussed. Sport stakeholders are encouraged to consider the wider social parameters of these issues, including cultures of secrecy and deference that too often facilitate abuse, rather than focusing simply on psychopathological causes. The promotion of safe sport is an urgent task and part of the broader international imperative for good governance in sport. A systematic multiagency approach to prevention is most effective, involving athletes, entourage members, sport managers, medical and therapeutic practitioners, educators and criminal justice agencies. Structural and cultural remedies, as well as practical recommendations, are suggested for sport organisations, athletes, sports medicine and allied disciplines, sport scientists and researchers. The successful prevention and eradication of abuse and harassment against athletes rests on the effectiveness of leadership by the major international and national sport organisations.

Background: The incidence rates (IRs) and factors associated with injuries in the sport of Paralympic athletics (track and field) have not been comprehensively and prospectively studied. Purpose: To determine injury IRs, characteristics of injuries, and associated factors in the sport of athletics at the London 2012 Paralympic Games. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 977 athletes competing in the sport of athletics were followed over a total 10-day competition period of the Paralympic Games. Daily injury data were obtained via 2 databases: (1) a custom-built, web-based injury and illness surveillance system (WEB-IISS), maintained by team medical personnel; and (2) the organizing committee database, maintained by medical providers in the medical stations operated by the London Organising Committee of the Olympic and Paralympic Games. Athlete impairment and event discipline were obtained via the International Paralympic Committee athlete database. IRs (injuries per 1000 athlete-days) by impairment, event discipline, sex, and age were examined. Results: The overall IR was 22.1 injuries per 1000 athlete-days (95% CI, 19.5-24.7). In track disciplines, ambulant athletes with cerebral palsy experienced a lower incidence of injuries (IR, 10.2; 95% CI, 4.2-16.2) when compared with ambulant athletes from other impairment categories. Athletes in seated throwing experienced a higher incidence of injuries (IR, 23.7; 95% CI, 17.5-30.0) when compared with athletes in wheelchair racing (IR, 10.6; 95% CI, 5.5-15.6). In both track and field disciplines, the majority of injuries did not result in time loss from competition or training. Ambulant athletes experienced the greatest proportion of injuries to the thigh (16.4% of all injuries; IR, 4.0), observed predominantly in track athletes. Wheelchair or seated athletes experienced the greatest proportion of injuries to the shoulder/clavicle (19.3% of all injuries; IR, 3.4), observed predominantly in field athletes. Conclusion: This is the first prospective cohort study examining injury IRs and associated factors in the sport of athletics at the Paralympic Games. Injury patterns were specific to the event discipline and athlete impairment. The majority of injuries occurred to the thigh (ambulant athletes) or shoulder/clavicle (wheelchair or seated athletes) and did not result in time loss.

Concussions to high-profile professional athletes and the $1 billion court settlement between the NFL in the USA and thousands of former NFL players have brought sports concussion to the top of news headlines.1 The crux of the NFL case centred around retired players’ allegation that the NFL did not warn them about the potential long-term health impact of concussions. Cases such as these alert sport governing bodies to the medicolegal importance of this issue and their responsibility for player safety. For the Para athlete, the International Paralympic Committee’s (IPC) term for a sportsperson with an impairment, the concussion debate struggles to garner attention. This is partly because funding for epidemiological research in this area is limited. But athletes with a variety of impairments due to a range of medical issues face the risks and consequences of concussive brain injury in Para sports: it is time for paralympic medical and sporting communities to address this important issue. Recommendations from the International Conferences on Concussion in Sport mandate that all potential cases of concussion undergo medical assessment, including a comprehensive history and detailed neurological …

In 1945, in the aftermath of World War II, former First Lady Eleanor Roosevelt (and wife of our first president with a disability when elected) was appointed by President Harry Truman to chair the United Nation’s (UN) Human Rights Commission. By all accounts, she relished the experience and recognized the moral force that a Universal Declaration of Human Rights could have in establishing international norms. In 1948, the UN Assembly adopted the Declaration. What followed over the subsequent decades were a series of UN human rights treaties and conventions that called out and underscored that various vulnerable populations (such as children, women, racial minority groups) deserved human rights protections too. Whereas, a UN declaration was intended to be aspirational and not legally binding, such was not the case with a human rights convention or treaty [2]. In addition to being a commitment to the international community, a convention also would require appropriate oversight and monitoring and reporting of the signatory countries. Unfortunately, concerns about national sovereignty have often impeded U.S. Senate ratification of UN human rights conventions, including the Convention on the Elimination of All Forms of Discrimination against Women, the Convention on the Rights of the Child, and, more recently, the Convention on the Rights of Persons with Disabilities (CRPD) [3]. Attention to the rights of people with disabilities has gained traction since the 1970s, both in the United States and internationally. In 1971, the UN General Assembly adopted The Declaration on the Rights of Mentally Retarded Persons, followed 4 years later by The Declaration on the Rights of Disabled Persons [4]. A push for civil rights laws for people with disabilities in the United States began in the 1960s, which culminated in such landmark legislation as Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA) in 1990. Not surprisingly, those who helped to draft the ADA in the United States also became leaders in the international movement for disability civil rights and helped to craft the language for the UN CRPD. The document, whose stated purpose is “to promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities, and to promote respect for their inherent dignity” [5] was adopted by the UN in 2006 and has been ratified by 141 countries to date [4]. Despite being signed by President Obama in 2009, efforts to obtain the supermajority (two-thirds or 66 votes) needed for U.S. Senate ratification have thus far fallen short. The reasons for opposition include concerns that the CRPD will infringe on parental rights, endorse abortion rights, and compromise U.S. sovereignty. To learn more about these issues, please see the fact sheet prepared by the U.S. International Council on Disabilities that addresses these concerns (http://www.usicd.org/doc/CRPD%20MythsFacts%200719%202013.pdf).

Individuals with disabilities experience a disproportionate rate of chronic disease and are more likely to lead sedentary lifestyles than the general population. Multiple complex factors likely contribute to these disparities, including structural, socioeconomic and attitudinal barriers that impede broad participation of individuals with disabilities in health and wellness promotion programs. Public health initiatives aimed at mitigating these health disparities emphasize improved access to physical activity and sports opportunities. Given its visibility, the Paralympic Movement provides an opportunity to transform how society conceptualizes the relationship of disability to physical fitness. The Paralympics also serve as a catalyst for public health education and program development. Already, public policies and governmental regulations are expanding grassroots sports opportunities for youth and adults with disabilities, thus promoting inclusive opportunities for participation in physical activity.

The Paralympic Movement explicitly sets out to create a more equitable society and promote participation for all and fairness in disability sport. This is primarily achieved through the use of a range of interventions with less attention given to how economic factors may hinder access and achievement in Paralympic sport. We investigated how country-level economic variables influence the level of participation and achievement in the 2015 International Paralympic Committee (IPC) Athletics Championships held in Doha. We used multiple regression analysis to show how levels of participation and achievement in the Championships were significantly determined by economic factors independent of population size. Our data show that in spite of the ideals of inclusion and fairness within the Paralympic Movement and the considerable effort expended on the use of technologies to achieve this, economic factors continue to exert a statistically significant influence on both the level of participation and achievement of Paralympic athletes. LMICs participate at lower levels and achieve fewer medals when compared to HICs. These differences are particularly marked in events that have a high cost of participation. Our findings raise questions regarding the use of current technologies and the level to which they are able to truly disrupt the politics of global inequality in sport.

Background ‘Boosting’ is defined as the intentional induction of autonomic dysreflexia (AD) by athletes with a spinal cord injury (SCI) at or above the level of T6 for the purpose of improving sports performance. Boosting has been shown to confer up to a 9.7% improvement in race time. Additionally, to compete in a hazardous dysreflexic state, whether intentional or unintentional, would present an extreme health risk to the athlete. For these reasons, the International Paralympic Committee strictly bans the practice of boosting, and has developed a protocol to test for its presence. Methods Testing was performed at three major international Paralympic events. Education regarding the dangers of AD was provided to athletes and team staff. Testing was conducted on athletes from the relevant sport classes: Athletics (wheelchair racing classes T51/T52/T53) and Handcycling (H1). Key parameters included the athlete9s demographics (gender, country of origin), classification and blood pressure measurements. An extremely elevated blood pressure was considered to be a proxy maker for AD, and a systolic blood pressure of ≥180 mm Hg was considered a positive test. Results A total of 78 tests for the presence of AD were performed during the three games combined. No athlete tested positive. The number of athletes tested, by classification, was: 6 in Athletics T51, 47 in Athletics T52, 9 in Athletics T53 and 16 in Handcycling H1. Of those tested, the average systolic and diastolic blood pressures were 135 mm Hg (range 98–178) and 82 mm Hg (range 44–112), respectively. All athletes were compliant with testing. No athletes were withdrawn from competition due to the presence of AD. Discussion Testing for the presence of AD in paralympic athletes with SCI prior to competition has been carried out for the first time at three major international paralympic competitions. There have been no positive tests thus far. Knowledge gained during these early testing experiences will be used to guide ongoing refinement of the testing protocol and the development of further educational initiatives.

In the United States, the Americans with Disabilities Act of 1990 exists to protect the employment rights of individuals with disabilities, to include nondiscrimination in hiring and promotions as well as access to reasonable accommodation for full accessibility of the workplace.1 Despite this, the rate of employment for adults with spinal cord injury (SCI) remains low as compared with that for the general population. The data from the 2010 Annual Report for the SCI Model Systems reveal that, 5 yrs after injury, approximately 20.7% of adults with SCI were competitively employed. This proportion peaks at 36% for those who are 25 yrs postinjury.2 These data are corroborated by the data retrieved from the United States Census Bureau revealing that, in 2008, a total of 28.7% of adults aged 21–64 yrs and with self-report of ambulatory disability were competitively employed.3 In contrast, the data from the United States Department of Labor, Bureau of Labor Statistics, reveal a civilian unemployment rate of 4.9%–10% for the general population older than 16 yrs throughout the years4 2008–2010. Although it is unknown whether these reports define employment uniformly, these data are suggestive of the ongoing disparity in rates of employment for adults with SCI when compared with the general population. It is commonly accepted that meaningful employment is a cornerstone of achieving self-efficacy and a sense of purpose into adulthood. Employment after SCI has been shown to be a critical component of life satisfaction, subjectively positive quality-oflife,5–10 and financial independence.11–13 Given this, much emphasis has been placed on the identification of social and demographic factors, in addition to targeted rehabilitation strategies, that may promote employment after SCI. Previous studies uniformly agree on factors such as level of education and functional independence as those positively correlated with employment.7,14–17 In addition, independent use of public or private transportation,7 white race,18,19 fewer medical complications,7 lack of concomitant brain injury,16 and inherently high motivation to work20 have also shown positive correlation. Of interest, neurologic level of injury and ambulatory status have shown mixed results in their association.14,16 In the ongoing effort to identify rehabilitation strategies that may stimulate employment after SCI, organized sports has come under investigation. Studies addressing the relationship between organized sports and employment have thus far shown mixed results. A German study focused on the effect of physical exercise on quality-of-life for adults with SCI reported that individuals involved in sports were also more likely to be employed.8 Countering this, Taseimski et al.21 found that, although both rates of participation in sports and employment decreased significantly after SCI, there was no association between the two. Similarly, Foreman et al.,22 in a study of the demographic and psychological factors that may influence sport participation, found no association between sports and employment status; however, the study did show that those with higher income were more likely to participate. Although several studies have linked fitness-related parameters to employment such as wheelchair mobility, body composition, power output, functional independence (as measured by the Functional Independence Measure), number of medical complications, and perceived exertion,23–25 few have directly investigated the association between organized sports and employment. Given these conflicting results and an overall paucity of information, this study aimed to determine the relationship between participation in organized sports and employment in a United States–based sample of adults with SCI.

Competitive sports for people with disabilities has grown rapidly over the past several decades, and opportunities for participation are increasingly available throughout the spectrum from developmental to elite. The Paralympic Games, seen as the pinnacle sporting event that represents the broader Paralympic Movement, has provided a platform to showcase the abilities of people with disabilities while also serving as a catalyst for disability rights through ensuring integration, equality of opportunity, and accessibility of the built environment. Concurrently, media coverage of the Paralympic Games has led to an increased awareness of opportunities for sport participation for individuals with disabilities and, with it, the adjustment of norms regarding expectations for exercise as a component of preventive health. In addition, there is evidence of the power of sports to stimulate confidence, self-efficacy, and a self-perceived high quality of life for individuals with disabilities above and beyond the basic benefits to cardiometabolic fitness. When taken together, the promotion of health, disability rights, and social integration through sports has the power to transform the lives of those who participate and to further stimulate the expansion of opportunities available to the next generation of athletes with disabilities.