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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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Maximum running speed is a performance determinant in para-athletics and cerebral palsy football. Sixty international para-athletes with brain impairments completed five activity-limitation tests (standing broad jump, four bounds for distance, split jumps, 10-m speed skip, and running in place) and two criterion tests (40-m sprint and modified agility test). The same three tests (standing broad jump, four bounds for distance, and 10-m speed skip) that correlated with running performance in nondisabled runners (.67 < r < -.82; p < .05; 75% of variance) also correlated in para-athletes with brain impairments (.41 < r < -.62; p < .01; 55% of variance). Standing broad jump, four bounds for distance, split jumps, and running in place also correlated with change-of-direction speed (.43 < r < -.63; p < .01; 58% of variance). Results indicate that methods of classification for para-athletics with nondisabled runners are also valid with para-athletes with brain impairments, and new sport-specific relationships were found for assessing the performance of rapid and short sprints toward different directions, specific of a team para-sport like cerebral palsy football.

Since publication of this paper (Royal Society open science, 2022. 9 (1): p. 211799), the authors have published a correction clarifying that the paper presents a case study that '… did not meet the definition for research with regard to human subjects'. The data are incorrectly referred to as experimental because the study has no experimental control. Furthermore, the paper has been presented previously but the version presented here selectively omits several analyses, posing a significant risk of bias. Of the prosthetic-related disadvantages identified by the authors, the most substantive was a 40% increase in time to 20 m (59.5 s.d. below the mean for NA sprinters). However the analysis was incomplete: acceleration modelling for NA sprinters continued up to 98% of maximum velocity, while Fastest BA was truncated at approximately 80%. We extrapolated the model, revealing the duration of maximum acceleration for Fastest BA is approximately 100% longer than NA sprinters. Important differences in Fastest BA contact lengths (0.10-0.15 m) were also identified. We posit that together, these large and important differences in sprint biomechanics and their likely physiological consequences suggest that running with and without prosthetics are so different that, although running times may be similar, the precautionary principle should apply and, in the interests of athletic competition integrity, runners with and without prosthetics should continue to compete separately., Competing Interests: We declare we have no competing interests., (© 2023 The Authors.)

Aim: To evaluate the longitudinal dietary patterns of three adolescents with moderate-to-severe cerebral palsy (CP) participating in a performance-focused swimming training intervention., Method: Participants were three previously inactive adolescents with CP (15-16 years, GMFCS IV) who had recently (<6 months) enrolled in a swimming training program. Diet quality from diet histories was calculated at 10-time points over 3.25 years using the Dietary Guidelines Index for Children and Adolescents (DGI-CA) and the Healthy Eating Index for Australian Adults (HEIFA-2013). A food group analysis was compared to the Australian Guide to Healthy Eating recommendations. Trends were considered in the context of dietary advice given and the training load., Results: Longitudinal diet quality scores were consistent and ranged from 40 to 76 (DGI-CA) and 33 to 79 (HEIFA-2013). Food group intake remained stable; participants rarely met the recommendations for fruit, vegetables, dairy, grain, and meat but frequently achieved discretionary serves., Conclusions: Participants with moderate-to-severe CP who were enrolled in a performance-focused swimming training intervention and were monitored frequently maintained diet quality throughout a period where it conventionally declined. Scores were higher than the general population and were maintained irrespective of the training load. Participants frequently met food group recommendations for discretionary foods and were comparable to the general population for other food groups.

Purpose: There is considerable variation in the physical and psychological presentations of people with whiplash-associated disorder (WAD). Optimal treatment continues to be a challenge. This research evaluated the efficacy of a community-located, theory-based intervention designed to promote physically active behaviour in people with persistent WAD, and thereby improve perceptions of pain interference and confidence completing activities in the presence of neck pain., Materials and Methods: A multiple-baseline, single-case experimental design was used to evaluate the 16-week intervention across six participants., Results: Weighted Tau- U showed significantly increased accelerometer-measured physical activity in three participants with large effect sizes (>0.5), with increased confidence in one participant (ES > 0.5), and reduced pain interference in another participant (ES > 0.7). Changes in other behaviours included clinically important improvements in quality of life for five participants and, in those participants with baseline symptom levels outside threshold levels, improvements in pain catastrophizing and pain self-efficacy., Conclusions: Participation in a theory-based intervention resulted in significant improvements in physical and psychological health for five of six participants. Providing this type of community-located physical activity promotion strategy, to individuals with persistent WAD, may help address physical impairments and psychological distress commonly experienced in WAD. Trial registration: The trial was registered with the Australia and New Zealand Clinical Trials Registry (ACTRN: ACTRN12617001261303p) and ClinicalTrials.gov (Protocol Number: 2018000349/2017/743).Implications for rehabilitationRehabilitation professionals should consider recommending theory-based physical activity promotion strategies to reduce physical impairments and psychological distress in individuals with persistent WAD.Individually tailored physical activity promotion strategies may help individuals with persistent WAD become more physically active thereby reducing their risk of diseases associated with inactivity which may compound the effects of WADImprovements in physical and psychological health may occur independently of increasing habitual physical activity.Rehabilitation professionals may find that other community-located strategies which aim to promote physically active behaviour confer similar benefits for individuals with persistent WAD.

Objectives: People with cerebral palsy and high support needs (CP&HSN) are profoundly inactive but also under-represented in studies evaluating physical activity interventions. Reasons for their exclusion have not been evaluated. We hypothesised that CP&HSN would be associated with high time costs of preparatory activities (eg, getting dressed/undressed), possibly contributing to low participation and under-representation. Accordingly, this pilot study aimed to: (1) evaluate whether the time required for preparatory activities was extremely different (≥3 SD) between swimmers with and without CP&HSN; and (2) provide a qualitative indication of the preparatory tasks undertaken by swimmers with CP&HSN., Methods: Each of three experienced (5 years) para swimmers with CP&HSN and 20 non-disabled swimmers were timed entering and then exiting the pool on three occasions. Mean entry and exit time for each para swimmer was compared with the group mean for non-disabled swimmers, and differences of greater than 3.0 SD were considered extreme. A qualitative description of the tasks completed by the para swimmers was recorded., Results: The differences in time costs between para and non-disabled swimmers met the criterion of extreme. Pool entry times for para swimmers were 8-13 times greater (Effect size = 4.1-8.7). Pool exit times were 6-10 times greater (ES=7.0-9.5). 90% of tasks completed by para swimmers required personal assistance or wheeled mobility., Conclusions: This pilot study suggests that, compared with non-disabled swimmers, time costs for preparation to commence or depart training are extremely high for swimmers with CP&HSN. Further research is required to evaluate the veracity of these findings., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Abstract: This study described bicycling (C classes) and tricycling (T classes) performance in the International Cycling Federation road race events between 2011 and 2019. A total of 3243 race results from 33 events were analyzed. Race velocity was calculated for each result. Bicycling and tricycling data were separately modeled using a linear mixed-effects model. Bicycling velocity was statistically different between all adjacent men's classes (Cohen d = 0.14-0.73) and between the women's C1 and C2 (d = 1.15) and C3 and C4 (d = 0.48) classes. The absence of statistical differences between some women's bicycling classes may be due to a limited number of observations in these classifications. As expected, velocity was statistically different between men's (d = 1.64) and women's (d = 1.38) T1 and T2 classes. Road race performance was hierarchical within the disciplines of bicycling and tricycling, although not all adjacent women's bicycling classes were statistically different. The existence of a performance hierarchy does not necessarily validate the classification system. The integration of information regarding athlete impairment type and severity, with performance data, would provide greater insight into the validity of the classification system and should be prioritized as an area of future research., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Measurement of maximum voluntary muscle contractions are effort-dependent - valid measurement requires maximal voluntary effort (MVE) from participants. Submaximal efforts (SMEs) yield invalid and potentially misleading results. This is particularly problematic in medico-legal and Para sport assessments where low strength scores may confer a personal advantage. Therefore, objective methods for accurately differentiating MVE and SME are required. This systematic review aimed to identify, appraise and synthesise evidence from scientific studies evaluating the validity of objective methods for differentiating MVE from SME during maximal voluntary contractions. Four electronic databases were searched for original research articles published in English and secondary references appraised for relevance yielding 25 studies for review. Methods were categorised based on eight distinct underlying theories. For isokinetic strength assessment, methods based on two theories - Strength-measure Ratios and Inter-Trial Strength Consistency - correctly classified 100% MVE and  >  92% SME. Consequently, research evaluating the relative suitability of these methods for translation into practice is warranted. During isometric strength assessments, methods based on Deceptive Visual Feedback and Force-length properties warrant further investigation. Both methods yielded statistically significant differences between MVE and SME, with minimal overlap in values, but their sensitivity and specificity have not been evaluated.

Conceptually, sports-specific training should not influence measures of impairment used to classify Para athletes. This study evaluated the extent to which measures of strength, range of movement and coordination developed for Para swimming classification changed in response to a performance-focused swimming programme. A five-phase multiple-baseline, single-case experimental research design was utilized. Three participants with cerebral palsy and high support needs completed the 64-week study, which included two 16-week performance-focused swimming training blocks. Swimming speed, isometric shoulder extension strength, shoulder flexion range of movement and upper limb coordination were monitored throughout.Interrupted Time-Series Simulation Method analysis demonstrated large, significant changes in swimming speed (m/s) during the first ( d =  2.17; 95% CI 0.45-3.88; p = 0.01) and second ( d =  2.59; 95% CI 1.66-3.52; p = 0.00) training blocks. In contrast, changes in strength, range of movement and coordination were predominantly trivial and non-significant. This was the first study to investigate training responsiveness of measures developed for Para sport classification. Results indicate that despite significantly improved swimming performance, impairment measures remained relatively stable, and therefore these measures of impairment may be valid for the purposes of Para swimming classification. Further research is required in elite athletes, different sports and different impairment types.

This study evaluated the validity of two wheelchair-mounted devices-the Cateye® and Wheeler-for monitoring wheelchair speed and distance traveled. Speed estimates were validated against a calibrated treadmill at speeds from 1.5 to 10 km/hr. Twenty-five wheelchair users completed a course of known distance comprising a sequence of everyday wheelchair activities. Speed estimate validity was very good (mean absolute percentage error ≤ 5%) for the Wheeleri at all speeds and for the Cateye at speeds >3 km/hr but not speeds <3 km/hr (mean absolute percentage error > 20%). Wheeleri distance estimates were good (mean absolute percentage error < 10%) for linear pushing activities and general maneuvering but poor for confined-space maneuvering. Cateye estimates were good for continuous linear propulsion but poor for discontinuous pushing and maneuvering (both general and confined space). Both devices provided valid estimates of speed and distance for typical wheelchair-based exercise activities. However, the Wheeleri provided more accurate estimates of speed and distance during typical everyday wheelchair activities.

Objective: A recent Apple Watch ® activity-monitoring innovation permits manual wheelchair users to monitor daily push counts. This study evaluated the validity of the Apple Watch ® push count estimate. Design: Criterion validity. Setting : Southern Finland and Southeast Queensland, Australia. Participants : Twenty-six manual wheelchair users from Finland and Australia were filmed completing a standardized battery of activities while wearing the Apple Watch ® (dominant wrist). Outcome Measures: Wheelchair pushes as determined by the Apple Watch ® were compared to directly observed pushes. Results: Agreement between Apple Watch ® push counts and directly observed pushes was evaluated using Intraclass correlation coefficients (ICC), Pearson correlations and Bland-Altman analyses. Apple Watch ® pushes and directly observed push counts were strongly correlated (ICC = 0.77, P  < 0.01) ( r  = 0.84, P  < 0.01). Bland Altman plots indicated that the Apple Watch ® underestimated push counts (M = -103; 95% ULoA = 217; LLoA = -423 pushes). Mean absolute percentage error was 13.5% which is comparable to studies evaluating agreement between pedometer-based step counts and directly observed steps. Conclusion: Apple Watch ® push-count estimates are acceptable for personal, self-monitoring purposes and for research entailing group-level analyses, but less acceptable where accurate push-count measures for an individual is required.

Objectives: Para athletes with brain impairment are affected by hypertonia, ataxia and athetosis, which adversely affect starting, sprinting and submaximal running. The aim was to identify and synthesise evidence from studies that have compared the biomechanics of runners with brain impairments (RBI) and non-disabled runners (NDR)., Design: Systematic review., Methods: Five journal databases were systematically searched from inception to March 2020. Included studies compared the biomechanics of RBI (aged>14 years) and NDR performing either block-starts, sprinting, or submaximal running., Results: Eight studies were included, analysing a total of 100 RBI (78M:22F; 18-38 years) diagnosed with either cerebral palsy (n=44) or traumatic brain injury (n=56). Studies analysed block-starts (n=3), overground sprinting (n=3) and submaximal running (n=2), and submaximal treadmill running (n=1). Horizontal velocity during starts, sprinting and self-selected submaximal speeds were lower in RBI. During sprinting and submaximal running, compared with NDR, RBI had shorter stride length, step length, and flight time, increased ground-contact time, increased cadence, and reduced ankle and hip range of motion. In submaximal running, RBI had decreased ankle-power generation at toe-off., Conclusions: There is limited research and small sample sizes in this area. However, preliminary evidence suggests that RBI had lower sprint speeds and biomechanical characteristics typical of submaximal running speeds in NDR, including increased ground-contact times and reduced stride length, step length, and flight times. Meaningful interpretation of biomechanical findings in RBI is impeded by impairment variability (type, severity and distribution), and methods which permit valid, reliable impairment stratification in larger samples are required., (Copyright © 2020 Sports Medicine Australia. All rights reserved.)

Half of individuals with a whiplash injury experience ongoing pain and disability. Many are insufficiently active for good health, increasing their risk of preventable morbidity and mortality, and compounding the effects of the whiplash injury. This paper describes a protocol for evaluating the efficacy of a physical activity promotion intervention in adults with whiplash associated disorders. A multiple-baseline, single case experimental design will be used to evaluate the effects of a physical activity (PA) intervention that includes evidence-based behaviour change activities and relapse prevention strategies for six adults with chronic whiplash. A structured visual analysis supplemented with statistical analysis will be used to analyse: accelerometer-measured PA, confidence completing PA in the presence of neck pain, and pain interference., Competing Interests: The Authors declare that there is no conflict of interest., (© 2019 The Authors.)

Objective: To describe the fitness, function, and exercise training responses of patients following reconstruction of the lower limb with a total femoral (TF), proximal femoral (PF), distal femoral (DF), or proximal tibial (PT) megaprosthesis. TYPE: Systematic review., Literature Survey: Five research databases were searched systematically for original studies published in English from 2006 to 2017 that reported fitness, functioning, or exercise training responses for one or more of the four types of lower limb megaprosthesis listed above., Methodology: Methodologic quality was assessed using a 22-item modified STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist., Synthesis: Of the 5342 articles retrieved, 28 met the inclusion criteria. Thirteen studies reported fitness outcomes, primarily in PT, with none in TF. Impaired knee extensor strength of the affected limb was reported following limb salvage with PF, DF, and PT megaprosthetics. Impaired flexibility was reported following limb salvage with DF and PT megaprosthetics. Functional outcomes were described in all studies and were most commonly reported using the Musculoskeletal Tumor Society (MSTS) system score. Results indicated no clear difference in functional outcomes between megaprosthesis locations. No studies evaluated exercise training responses., Conclusions: This review identified impairments of lower limb strength and flexibility following limb salvage with a lower limb megaprosthesis. Similarity in functional outcomes for all four reported megaprosthetic locations may indicate a lack of sensitivity in outcome measures, including the absence of items assessing higher-level functioning. Exercise interventions that aim to improve fitness and function in this population have not been evaluated but are required given increasing 5-year survival rates., Level of Evidence: I., (© 2018 American Academy of Physical Medicine and Rehabilitation.)

Background: The Para athletics wheelchair-racing classification system employs best practice to ensure that classes comprise athletes whose impairments cause a comparable degree of activity limitation. However, decision-making is largely subjective and scientific evidence which reduces this subjectivity is required., Aim: To evaluate whether isometric strength tests were valid for the purposes of classifying wheelchair racers and whether cluster analysis of the strength measures produced a valid classification structure., Methods: Thirty-two international level, male wheelchair racers from classes T51-54 completed six isometric strength tests evaluating elbow extensors, shoulder flexors, trunk flexors and forearm pronators and two wheelchair performance tests-Top-Speed (0-15 m) and Top-Speed (absolute). Strength tests significantly correlated with wheelchair performance were included in a cluster analysis and the validity of the resulting clusters was assessed., Results: All six strength tests correlated with performance (r=0.54-0.88). Cluster analysis yielded four clusters with reasonable overall structure (mean silhouette coefficient=0.58) and large intercluster strength differences. Six athletes (19%) were allocated to clusters that did not align with their current class. While the mean wheelchair racing performance of the resulting clusters was unequivocally hierarchical, the mean performance of current classes was not, with no difference between current classes T53 and T54., Conclusions: Cluster analysis of isometric strength tests produced classes comprising athletes who experienced a similar degree of activity limitation. The strength tests reported can provide the basis for a new, more transparent, less subjective wheelchair racing classification system, pending replication of these findings in a larger, representative sample. This paper also provides guidance for development of evidence-based systems in other Para sports., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objectives: To evaluate the reliability of swimming-specific range of movement tests developed in order to permit evidenced-based classification in the sport of para swimming., Design: Test-retest intra- and inter-examiner reliability., Setting: International Swimming training camps and university exercise science departments., Participants: 42 non-disabled participants (mean age 23.2 years) and 24 Para swimmers (mean age 28.5 years)., Main Outcome Measures: Intra- and inter-examiner reliability of a battery of novel active range of motion tests., Results: Good to excellent intra-examiner reliability was found for the majority (32/34) of tests in non-disabled participants (ICC = 0.85-0.98). SEM values ranged from 1.18° to 6.11°. Similarly, good to excellent inter-examiner reliability was found for the majority (35/42) of tests in non-disabled participants (ICC = 0.85-0.98). SEM values range from 0.73° to 6.52°. Para swimmers exhibited significantly reduced range of motion compared to non-disabled participants., Conclusions: The large majority of ROM tests included in this novel battery were reliable both within and between examiners in non-disabled participants. The tests were found to differentiate between non-disabled participants and Para swimmers with hypertonia or impaired muscle power., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Para-sport classification systems define eligibility for Para sport and provide a competition structure that controls for the impact of impairment on the outcome of competition. This article focuses on the classification of para athletes with physical impairments. Development of classification systems based on scientific evidence has only recently been made possible by adoption of a statement of the purpose of classification by the International Paralympic Committee and its member organizations. Rigorous descriptive science can improve extant systems of classification and a recently published study described a data-driven classification structure with validity superior to that of the extant system., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: Classification in Paralympic Sport aims to minimize the impact of 10 eligible types of impairment on the outcome of competition. Methods for assessing the extent to which a given body structure or function has been impaired are required, but are challenging because it is not possible to directly measure an absence or loss. Rather, impairment must be inferred by measurement of extant body structures or functions., Methods: This manuscript reviews the literature concerning the assessment of strength with the aim of identifying and describing the most appropriate method for inferring strength impairment in para-athletes., Results: It is posited that the most appropriate voluntary strength assessment method for inferring strength loss in para-athletes will be multi-joint, isometric tests performed at joint angles that facilitate maximum force production., Conclusions: Evidence suggests such methods will permit development of tests that are specific to a variety of para-sports and which are reliable, ratio-scaled, and resistant to training. Future research should: develop sport-specific tests which are suitable for assessment of athletes with strength impairments of variable severity and distribution; and scientifically evaluate the extent to which such tests permit strength impairment to be validly inferred, including specific evaluation of the extent to which such measures respond to athletic training., (Copyright © 2016 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

Traumatic spinal cord injury (SCI) may result in tetraplegia (motor and/or sensory nervous system impairment of the arms, trunk and legs) or paraplegia (motor and/or sensory impairment of the trunk and/or legs only). The adverse effects of SCI on health, fitness and functioning are frequently compounded by profoundly sedentary behaviour. People with paraplegia (PP) and tetraplegia (TP) have reduced exercise capacity due to paralysis/paresis and reduced exercising stroke volume. TP often further reduces exercise capacity due to lower maximum heart-rate and respiratory function. There is strong, consistent evidence that exercise can improve cardiorespiratory fitness and muscular strength in people with SCI. There is emerging evidence for a range of other exercise benefits, including reduced risk of cardio-metabolic disease, depression and shoulder pain, as well as improved respiratory function, quality-of-life and functional independence. Exercise recommendations for people with SCI are: ≥30min of moderate aerobic exercise on ≥5d/week or ≥20min of vigorous aerobic ≥3d/week; strength training on ≥2d/week, including scapula stabilisers and posterior shoulder girdle; and ≥2d/week flexibility training, including shoulder internal and external rotators. These recommendations may be aspirational for profoundly inactive clients and stratification into "beginning", "intermediate" and "advanced" will assist application of the recommendations in clinical practice. Flexibility exercise is recommended to preserve upper limb function but may not prevent contracture. For people with TP, Rating of Perceived Exertion may provide a more valid indication of exercise intensity than heart rate. The safety and effectiveness of exercise interventions can be enhanced by initial screening for autonomic dysreflexia, orthostatic hypotension, exercise-induced hypotension, thermoregulatory dysfunction, pressure sores, spasticity and pain., (Copyright © 2016 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

The International Paralympic Committee has a maximum allowable standing height (MASH) rule that limits stature to a pre-trauma estimation. The MASH rule reduces the probability that bilateral lower limb amputees use disproportionately long prostheses in competition. Although there are several methods for estimating stature, the validity of these methods has not been compared. To identify the most appropriate method for the MASH rule, this study aimed to compare the criterion validity of estimations resulting from the current method, the Contini method, and four Canda methods (Canda-1, Canda-2, Canda-3, and Canda-4). Stature, ulna length, demispan, sitting height, thigh length, upper arm length, and forearm length measurements in 31 males and 30 females were used to calculate the respective estimation for each method. Results showed that Canda-1 (based on four anthropometric variables) produced the smallest error and best fitted the data in males and females. The current method was associated with the largest error of those tests because it increasingly overestimated height in people with smaller stature. The results suggest that the set of Canda equations provide a more valid MASH estimation in people with a range of upper limb and bilateral lower limb amputations compared with the current method., (© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Individuals with brain impairment (BI) are less active than the general population and have increased risk of chronic disease., Objective: This controlled trial evaluated the efficacy of a physical activity (PA) intervention for community-dwelling adults with BI., Methods: A total of 43 adults with BI (27 male, 16 female; age 38.1 ± 11.9 years; stage of change 1-3) who walked as their primary means of locomotion were allocated to an intervention (n = 23) or control (n = 20) condition. The intervention comprised 10 face-to-face home visits over 12 weeks, including a tailored combination of stage-matched behavior change activities, exercise prescription, community access facilitation, and relapse prevention strategies. The control group received 10 face-to-face visits over 12 weeks to promote sun safety, healthy sleep, and oral health. Primary outcomes were daily activity counts and minutes of moderate-to-vigorous-intensity PA (MVPA) measured with the ActiGraph GT1M at baseline (0 weeks), postintervention (12 weeks) and follow-up (24 weeks). Between-group differences were evaluated for statistical significance using repeated-measures ANOVA., Results: MVPA for the intervention group increased significantly from baseline to 12 weeks (20.8 ± 3.1 to 31.2 ± 3.1 min/d; P = .01), but differences between baseline and 24 weeks were nonsignificant (20.8 ± 3.1 to 25.3 ± 3.2 min/d; P = .28). MVPA changes for the control group were negligible and nonsignificant. Between-group differences for change in MVPA were significant at 12 weeks (P = .03) but not at 24 weeks (P = .49)., Conclusion: The 12-week intervention effectively increased adoption of PA in a sample of community-dwelling adults with BI immediately after the intervention but not at follow-up. Future studies should explore strategies to foster maintenance of PA participation., (© The Author(s) 2016.)

Objectives: Development of evidence-based methods of Paralympic classification requires research quantifying the relative strength of association between ratio-scaled measures of impairment and athletic performance. The purpose of this study was to quantify the extent to which muscle strength affects running performance in runners with and without brain impairment., Design: Cross-sectional study., Methods: Participants were 41 male runners: 13 with brain impairments (RBI) and 28 non-disabled (NDR). All participants completed a maximal 60-m sprint and a novel battery of three lower limb isometric strength tests., Results: RBI showed significantly lower strength scores compared with NDR on the more affected side in leg flexion (176 vs. 243 N), leg extension (993 vs. 1661 N) and plantarflexion (824  vs. 1457 N). Significant differences were also seen on the less affected side in plantarflexion (1072 vs. 1508 N). RBI were significantly slower in the acceleration phase (0-15 m) (3.2 s ± 0.3 vs. 2.8 s ± 0.2) and top speed phase (30-60 m) (4.3 s ± 0.6 vs. 3.8 s ± 0.3). Correlation analysis showed stronger relationships between strength and running performance in RBI than NDR; however, the correlations were not significant., Conclusions: This study evaluated measures to assess strength for the purposes of classification and found that the measures were significantly different in RBI compared with NDR indicating the tests were able to capture strength impairment in this population. This study indicates that strength may be an important impairment type to assess in this population, as impairments of muscle strength may influence the outcome of running performance in athletes with more severe impairments.

In paralympic classification, tests of impaired coordination (e.g., reciprocal tapping tasks) are effort dependent and therefore susceptible to intentional misrepresentation of abilities (IM)-deliberate exaggeration of impairment severity. The authors investigated whether reciprocal tapping tasks performed submaximally could be differentiated from tapping tasks performed with maximal voluntary effort, based on conformity with Fitts' law. Ten nondisabled participants performed 14 tapping tasks with their dominant hand on 3 separate occasions. Seven tasks were performed with MVE and the other 7 at speeds that were at least 20% slower. Results revealed that evaluating conformity with Fitts' law is a potentially valid method for objectively detecting IM during reciprocal tapping. Evaluation of sensitivity and specificity of the method is now warranted.

Introduction: Development of evidence-based methods of paralympic classification requires research quantifying the relative strength of association between ratio-scaled measures of impairment and sports performance. To date, no such research has been conducted. The purpose of this study was to quantify the extent to which range of movement (ROM) and coordination affect running performance in runners with and without brain impairment., Methods: Participants were 41 male runners, 13 with brain impairments (RBI) and 28 nondisabled (NDR). All participants completed a maximal 60-m sprint as well as a novel battery of five lower limb ROM tests and three lower limb coordination tests., Results: In the coordination tests, RBI showed significantly slower mean movement times compared to NDR on all measures (e.g., 0.54 s ± 0.12 s vs 0.34 s ± 0.05 s). Runners with brain impairments had significantly lower range of movement on five of ten measures (e.g., 25.9° ± 5.4° vs 37.0° ± 6.0°) and had significantly slower acceleration (0-15 m) (3.2 s ± 0.3 s vs 2.8 s ± 0.2 s) and top speed (30-60 m) (4.3 s ± 0.6 s vs 3.8 s ± 0.3 s). Five ROM measures significantly correlated with sprint performance in RBI and did not significantly correlate with sprint performance in NDR, satisfying convergent and divergent validity criteria. These individual tests explained 38% to 58% of the variance in sprint performance in RBI., Conclusion: This is the first study to quantify the extent to which eligible impairments affect performance in a paralympic sport. Five of the ROM measures significantly affected sprint performance in RBI and were deemed valid for the purposes of classifying impairments in classes T35-T38. This study is an important methodological step toward development of evidence-based methods of classifying impairments in classes T35-T38 and provides practical methodological guidance to researchers in this field.

Marathon runners are ranked in 5-year age groups. However the extent to which 5-year groupings facilitates equitable competition has not been evaluated. The aim of this study was to evaluate the effect of relative age in male and female marathon running. Marathon finishing times for the top ten male (aged 20-69 years) and female athletes (aged 20-64 years) were obtained from the 2013 New York and Chicago marathons. Intra-class and inter-class validity were evaluated by comparing performances within (intra-class) and between (inter-class) the 5-year age groups. Results showed intra-class effects in all male age groups over 50 years, in all female age groups over 40 years, and in male and female 20-24 age groups (p < 0.05). Inter-class differences existed between the 20-24 and 25-29 age groups in both males and females, between all male age groups over 50 years, and between all female age groups over 40 years (p < 0.05). This study provided the first evaluation of the effects of relative age in male and female marathon running. The results provide preliminary but compelling evidence that the relatively older male athletes in age groups over 50 years and the relatively older females in age groups over 40 years are competitively disadvantaged compared to the younger athletes in these age groups. Key pointsResults showed a curvilinear relationship between age and marathon running performance with the negative effect of age becoming more pronounced in older runners.Relative age effects were found in all age groups over age 50 years in males and over age 40 years in females indicating that the relatively older runners were competitively disadvantaged compared to the relatively younger runners in these age groups.Relative age affected the 20-24 age classification which is consistent with the hypothesis that marathon performance improves until peak performance occurs in the 25-29 age classification.

Paralympic throwing events for athletes with physical impairments comprise seated and standing javelin, shot put, discus and seated club throwing. Identification of talented throwers would enable prediction of future success and promote participation; however, a valid and reliable talent identification battery for Paralympic throwing has not been reported. This study evaluates the reliability and validity of a talent identification battery for Paralympic throws. Participants were non-disabled so that impairment would not confound analyses, and results would provide an indication of normative performance. Twenty-eight non-disabled participants (13 M; 15 F) aged 23.6 years (±5.44) performed five kinematically distinct criterion throws (three seated, two standing) and nine talent identification tests (three anthropometric, six motor); 23 were tested a second time to evaluate test-retest reliability. Talent identification test-retest reliability was evaluated using Intra-class Correlation Coefficient (ICC) and Bland-Altman plots (Limits of Agreement). Spearman's correlation assessed strength of association between criterion throws and talent identification tests. Reliability was generally acceptable (mean ICC = 0.89), but two seated talent identification tests require more extensive familiarisation. Correlation strength (mean rs = 0.76) indicated that the talent identification tests can be used to validly identify individuals with competitively advantageous attributes for each of the five kinematically distinct throwing activities. Results facilitate further research in this understudied area.

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., (Copyright © 2014 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Ordinal-scale strength assessment methods currently used in Paralympic athletics classification prevent the development of evidence-based classification systems. This study evaluated a battery of 7, ratio-scale, isometric tests with the aim of facilitating the development of evidence-based methods of classification. This study aimed to report sex-specific normal performance ranges, evaluate test-retest reliability, and evaluate the relationship between the measures and body mass.Body mass and strength measures were obtained from 118 participants-63 males and 55 females-ages 23.2 years ± 3.7 (mean ± SD). Seventeen participants completed the battery twice to evaluate test-retest reliability. The body mass-strength relationship was evaluated using Pearson correlations and allometric exponents.Conventional patterns of force production were observed. Reliability was acceptable (mean intraclass correlation = 0.85). Eight measures had moderate significant correlations with body size (r = 0.30-61). Allometric exponents were higher in males than in females (mean 0.99 vs 0.30).Results indicate that this comprehensive and parsimonious battery is an important methodological advance because it has psychometric properties critical for the development of evidence-based classification. Measures were interrelated with body size, indicating further research is required to determine whether raw measures require normalization in order to be validly applied in 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.

To evaluate the validity of the ActiGraph accelerometer for the measurement of physical activity intensity in children and adolescents with cerebral palsy (CP) using oxygen uptake (VO(2)) as the criterion measure. Thirty children and adolescents with CP (mean age 12.6 ± 2.0 years) wore an ActiGraph 7164 and a Cosmed K4b(2) portable indirect calorimeter during four activities; quiet sitting, comfortable paced walking, brisk paced walking and fast paced walking. VO(2) was converted to METs and activity energy expenditure and classified as sedentary, light or moderate-to-vigorous intensity according to the conventions for children. Mean ActiGraph counts min(-1) were classified as sedentary, light or moderate-to-vigorous (MVPA) intensity using four different sets of cut-points. VO(2) and counts min(-1) increased significantly with increases in walking speed (P < 0.001). Receiver operating characteristic (ROC) curve analysis indicated that, of the four sets of cut-points evaluated, the Evenson et al. (J Sports Sci 26(14):1557-1565, 2008) cut-points had the highest classification accuracy for sedentary (92%) and MVPA (91%), as well as the second highest classification accuracy for light intensity physical activity (67%). A ROC curve analysis of data from our participants yielded a CP-specific cut-point for MVPA that was lower than the Evenson cut-point (2,012 vs. 2,296 counts min(-1)), however, the difference in classification accuracy was not statistically significant 94% (95% CI = 88.2-97.7%) vs. 91% (95% CI = 83.5-96.5%). In conclusion, among children and adolescents with CP, the ActiGraph is able to differentiate between different intensities of walking. The use of the Evenson cut-points will permit the estimation of time spent in MVPA and allows comparisons to be made between activity measured in typically developing adolescents and adolescents with CP.

The purpose of this study was to evaluate the extent to which residual shank length affects long jump performance of elite athletes with a unilateral transtibial amputation. Sixteen elite, male, long jumpers with a transtibial amputation were videoed while competing in major championships (World Championships 1998, 2002 and Paralympic Games, 2004). The approach, take-off, and landing of each athlete's best jump was digitized to determine residual and intact shank lengths, jump distance, and horizontal and vertical velocity of center of mass at touchdown. Residual shank length ranged from 15 cm to 38 cm. There were weak, nonsignificant relationships between residual shank length and (a) distance jumped (r = 0.30), (b) horizontal velocity (r = 0.31), and vertical velocity (r = 0.05). Based on these results, residual shank length is not an important determinant of long jump performance, and it is therefore appropriate that all long jumpers with transtibial amputation compete in the same class. The relationship between residual shank length and key performance variables was stronger among athletes that jumped off their prosthetic leg (N = 5), and although this result must be interpreted cautiously, it indicates the need for further research.

Aim: This systematic review compares the validity, reliability, and clinical use of habitual physical activity (HPA) performance measures in adolescents with cerebral palsy (CP)., Method: Measures of HPA across Gross Motor Function Classification System (GMFCS) levels I-V for adolescents (10-18 y) with CP were included if at least 60% of items reported HPA performance in the domains of intensity, frequency, duration, and mode., Results: Seven measures of HPA performance met the criteria: StepWatch, pedometers, Uptimer, heart rate flex method, accelerometers, and self-report measures including the Children's Activity Participation and Enjoyment (CAPE) scale and the Physical Activity Questionnaire for Adolescents. The CAPE scale had the strongest validity and reliability but was limited by its inability to measure activity intensity. No study was identified that evaluated the psychometric properties of physical activity measures in non-ambulant adolescents with CP (GMFCS levels IV and V)., Interpretation: When deciding on an appropriate measure of HPA in adolescents with CP, clinicians need to consider their research question including the domains of HPA they are evaluating and the population they wish to assess. Accelerometers provide the most robust information about the patterns of HPA, with some evidence of validity but limited data on reliability. Further research is needed to compare the use of tri- and uniaxial accelerometers., (© The Authors. Developmental Medicine & Child Neurology © 2011 Mac Keith Press.)

Background: Cerebral 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/methods: This 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., Discussion: This 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.

Purpose: To evaluate the validity of a uniaxial accelerometer (MTI Actigraph) for measuring physical activity in people with acquired brain injury (ABI) using portable indirect calorimetry (Cosmed K4b(2)) as a criterion measure., Methods: Fourteen people with ABI and related gait pattern impairment (age 32 +/- 8 yr) wore an MTI Actigraph that measured activity (counts.min(-1)) and a Cosmed K4b(2) that measured oxygen consumption (mL.kg(-1).min(-1)) during four activities: quiet sitting (QS) and comfortable paced (CP), brisk paced (BP), and fast paced (FP) walking. MET levels were predicted from Actigraph counts using a published equation and compared with Cosmed measures. Predicted METs for each of the 56 activity bouts (14 participants x 4 bouts) were classified (light, moderate, vigorous, or very vigorous intensity) and compared with Cosmed-based classifications., Results: Repeated-measures ANOVA indicated that walking condition intensities were significantly different (P < 0.05) and the Actigraph detected the differences. Overall correlation between measured and predicted METs was positive, moderate, and significant (r = 0.74). Mean predicted METs were not significantly different from measured for CP and BP, but for FP walking, predicted METs were significantly less than measured (P < 0.05). The Actigraph correctly classified intensity for 76.8% of all activity bouts and 91.5% of light- and moderate-intensity bouts., Conclusions: Actigraph counts provide a valid index of activity across the intensities investigated in this study. For light to moderate activity, Actigraph-based estimates of METs are acceptable for group-level analysis and are a valid means of classifying activity intensity. The Actigraph significantly underestimated higher intensity activity, although, in practice, this limitation will have minimal impact on activity measurement of most community-dwelling people with ABI.

Developing a unified classfication system to replace four of the systems currently used in disability athletics (i.e., track and field) has been widely advocated. The diverse impairments to be included in a unified system require several assessment methods, results of which cannot be meaningfully compared. Therefore, the taxonomic basis of current classification systems is invalid in a unified system. Biomechanical analysis establishes that force, a vector described in terms of magnitude and direction, is a key determinant of success in all athletic disciplines. It is posited that all impairments to be included in a unified system may be classified as either force magnitude impairments (FMI) or force control impairments (FCI). This framework would provide a valid taxonomic basis for a unified system, creating the opportunity to decrease the number of classes and enhance the viability of disability athletics.

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.