Hi everyone, my name is Johan. I'm the current Adaptive Sports Community Chair. And so I quickly wanted to introduce myself and the rest of the board members that you had recently voted on. And then I will introduce our speaker, Dr. Tao here. So like I said, my name is Johan and I am currently at UAB and I did all my residency of fellowship training in sports medicine at the University of Michigan. I've been interested in adaptive sports since I was a medical student and I've been fortunate enough to work with Dr. L at the University of Michigan and kind of flourish with the adaptive sports program there. And then ultimately here at the UAB, I'm one of the team physicians for Team USA Wheelchair Rugby, who is going to Paris this summer and hopefully bring it back in gold. So I now wanna introduce our first board member, our vice chair, which is Jeremy Roberts. Go ahead, Jeremy. Hi, thanks, Johan. Hi, I'm Jeremy Roberts. I'm a PGY-6 Peds Rehab Fellow graduating in June and then I'll be a PGY-7 Sports Medicine Fellow at Morristown Medical Center coming up this summer. And I'm excited to work with the rest of the team. Thanks, Jeremy. And the next we have Austin. Hey all, this is Austin Henke. I am down at Baylor Dallas, Spinal Cord Injury Fellow trained, but also huge interest in adaptive sports since I was in medical school. So hoping to be a part of the crew. And next up is Anusha. Hi, everyone. I am Anusha. I work at Westchester Medical Center as the PM&R in sports attending with the department and also as one of the attendings for the, or one of the assistant professors for the New York Medical College student. And then last up, we have Selena. Well, I guess we'll wait for Selena and then Caitlin, you can go first here. Hey, everyone. I'm Caitlin. I'm a sophomore at Shirley Ryan Ability Lab slash Northwestern and then I'll be starting my sports fellowship here this upcoming summer and excited to be with you guys. All right. Selena, you're last up. Yeah, sorry about that. I'm Selena. I'm a third year resident at Mary Free Bed. Yeah. Working with the chair for education for adaptive sports. Awesome. So thanks again, guys, for coming for this talk and thank you for a PM&R for setting up Member May. We'll have, keep up with this forum and if we have our emails, you'll also get our emails about different things we're trying to start up with initiatives such as different lectures and different compilations of different, you know, articles and adaptive sports, templates for providers and events throughout the country and much, much more. So just keep an eye out so that if you wanna help out with trying to create these libraries and other types of content, you'll be hearing from us. So I wanna now move over to our speaker, Dr. Stephanie Tao. So Dr. Stephanie Tao is currently at the University of Colorado, as you can see here on her slides. She is an amazing physician who is, did two fellowships in pediatrics and in sports. Jeremy wanted a copy or it seems like and she's also on top of that, the head team physician for Paralympic Team USA Swimming. And she has a lot of extensive experience of classifications and what she will be talking to you about today. So thank you for joining us today, Dr. Tao and please take it ahead. Thank you, Dr. Ofer. So full disclosure, I'm coming, I'm overcoming an illness right now. So I'm sorry that my voice is not as clear as it usually is. And it sounds like there's like a frog in my throat. Hopefully I don't lose my voice during this talk. So I'm excited to talk to you guys today about Paralympic sport classification and some of the controversies with it. I started getting involved officially with Paralympic swimming as a medical classifier. And then over time evolved into the role of their head team physician. And I think there was a lot that I ended up seeing with my background as a classifier, but then realized a lot more when I started taking a lot of medical care of our athletes that I did not realize when I was a classifier. And so hopefully from today's talk, you'll be able to learn some of the things I've learned. So I have no financial disclosures related to this talk. I do just have some volunteer roles, my head team physician role and my medical classifier role with U.S. Paralympic swimming. And then I also volunteer in various adaptive sports roles, including as a sit ski instructor for the NSED at Winter Park. So my objectives for today. At the end of this program, I hope that you'll be able to provide an overview of the classification process in Paralympic sports. We'll talk about some of the controversies and future directions in classification. And then we'll hopefully be able to allow you to apply some of these considerations we talked about today to provide more comprehensive care for your patients who could be potential Paralympic athletes or adaptive sports athletes at various levels. So here's our outline today. We're gonna go through a case example, and then we'll talk about the purpose of classification and how or what it's meant to be. We'll give you some examples of what classification is, like how it works in individual sports versus team sports. And then we'll talk, we'll delve into some of the controversies that currently exist and some issues with it, and then some medical considerations, and then we'll wrap up. So case one, you're traveling with part of the Team USA Paralympic Swimming National Team to a World Series competition internationally, and this is your first trip with the team. One of the athletes traveling with you is a 28-year-old female Paralympic swimmer with a history of generalized dystonia. You overheard this athlete telling others that she is extremely nervous about her classification appointment. She is currently classified as an S4, SB3, SM4. Later in the day, the team is practicing at a local pool and the athlete is having a seizure in the locker room, and she has no prior history of seizures. You get her transported to the closest emergency department and stay with her, and upon further testing in the emergency department, you find out that she was hypoglycemic, and that's why they think she had her seizure. So there's a lot of things going on in your head through this whole process, and you finally sit down later in the day and have some time to think about it, and you say, well, what's classification? What does the classification process entail? Why was this athlete's classification to begin with that they weren't eating and then they got hypoglycemic and had seizures? What are some of the other medical implications or risks that can happen with classification, and how do you prevent an adverse event like this happening again? So let's talk about what classification is or what it's meant to be. So in all competitive sports, we all have a way for people to compete fairly or try to compete fairly to level the playing field, right? So in able-bodied sports, and I'm gonna refer to, I'm gonna refer to able-bodied sports today as able-bodied. There's a lot of different cultural things around language, but that's how we'll refer to it today. So in able-bodied sports, we have classification, it's just no one calls it that, right? So people compete by age, by their sex. In some sports, you might compete by weight class, like in boxing or judo. But then in Paralympic sports, you've also got to deal with athletes' underlying eligible medical conditions and their impairments and how that impairment impacts the sport. And so basically what classification does is it takes that eligibility component with the medical diagnoses and their impairments and it levels the playing field by evaluating athletes on how their impairment impacts them in the functions central for that sport, and then putting them in different categories to compete by with theoretically those categories being, so their sport class, those categories being level playing field by looking at just their impairments. And so the origins of classification, there's a lot of different, like even when I was just chatting to one of my mentors, who's a Paralympian herself in clinic earlier this week about the origins of classification, there's different stories out there, but one of the references we hear most commonly in the literature is what it being mentioned in Joan Scraton's book, Stoke Mandeville, Road to the Paralympics. And in that book, it's mentioned that classification was created to make the sport of netball, which is the precursor of wheelchair basketball, a fair competition. And so back then it started with just athletes with spinal cord injury and they divided them into two classes, those who had complete lesions and those with incomplete lesions. And that was in 1955. And as you can imagine, right? Like, as we all know, as PM and our physicians, well, a complete lesion and an incomplete lesion, okay, great, that's great that you separated those, but within those categories, everyone's so different functionally, right? So, but they had to start somewhere. And so that was the starting point. And then since then, classification has been constantly evolving over time. And we're gonna talk a little bit about some of that today. So there are three steps that you need to remember for classification. The first, and so basically this determines if an athlete is eligible to compete in a Paralympic sport and also at what sport class, okay? So the first thing you need to look at is their medical history and they have to have an eligible medical condition and then an eligible medical impairment that is related to that medical condition, okay? So for example, if you have fibromyalgia or if you have chronic respiratory impairment, right? Like we know those are very impairing diagnoses, but under the Paralympic umbrella, those are not recognized as eligible medical conditions. If you have a spinal cord injury, but then you, or maybe that's not a good example. If you have an amputation from, let's say you had an osteosarcoma, but then you also have like a movement disorder on top of that, but there's no known cause for the movement disorder, they can only look at that amputation because the movement disorder needs to, they need to have an underlying medical clinician that is permanent so that they know that that impairment will also be permanent. And so the reasoning for that is because there's a lot of different things that can cause movement disorders, right? You can have a functional neurologic disorder that could get better over time or can fluctuate. You can have a weird dystonia. And so there needs to be documentation of an eligible medical clinician and impairment. The next step once that's all verified is does the athlete meet the minimum disability criteria? And this is sports specific. And the first one's also sports specific. So for, we'll talk a little bit, I'll show you guys a table, but every sport has its own list of what they consider eligible impairments and therefore what are eligible medical clinicians. But with any sport too, there's also different criteria and if they meet the minimum criteria to participate. So meaning are they quote unquote disabled enough to be put in the least involved class at minimum? And so that is where they undergo the classification process itself. They're medically evaluated through a physical exam by a classification panel. And then if the classification panel evaluates them and determines if they're eligible or not and what sport class they're given, which is step three, their allocation of their sport class. So the old system, and this was maybe like 10 years ago, it used to be, but if you think back to that netball example, it was very simple. So even up until 10 years ago, the old system was that everyone's classification was based on their medical diagnosis and everyone got the same class for all the sports. But then you realize, well, that's silly. Every sport has different functions, biomechanics, requirements of the human body. And so the new classification system, then this is the biggest update, was that it needs to be based on a functional assessment where it's specific. The functional assessment needs to be determined by the underlying medical diagnosis. So for instance, if you have an amputation, I'm not gonna evaluate for spasticity because you shouldn't have spasticity unless you have a brain injury on top of it. But the main thing here is that it's more focused on function related to the individual sport. And so with this new system, now every sport has had to develop its own system of how to evaluate classification. And certainly some sports borrow different methodology from other sports, but they should be tweaking it to things that are particular for that sport. For classification panels. So if an athlete undergoes classification, it has to be at an officially sanctioned event where there's an official Paralympic classification panel. So you can't just do this in clinic, but the classification panel usually entails one medical classifier and one technical classifier. The medical classifier, and again, this is dependent on sport, but the medical classifier is typically a physician or a physical therapist for physical impairments. For visual impairments, it's usually an ophthalmologist or optometrist. And then for intellectual impairments, it's a psychologist or a neuropsychologist. And then for technical classifiers, they have less restrictions, but they usually like to see someone who has more extensive background in that sport or extensive coaching experience or scientific background in biomechanics, sports science, or anatomy. And so sometimes people who are medical, but are not a physician or a physical therapist can go under this category as well. I've seen some of our para swimming technical classifiers as occupational therapists, or nurse practitioners or APP, like PAs might not be able to be medical classifier, but they could be a technical classifier. The caveat here is sometimes a technical classifier may not be available. So a medical classifier can sub in for a technical classifier. So sometimes you might have two medicals on a classification panel, but they need to be skilled enough to take a look at the technical aspects within the sport too. And usually most sports will take medical, they will train medical classifiers who have some extensive background in the sport, because it's usually, I know for para swimming it's pretty competitive to become a medical classifier. The last course they did was in 2017 and they only trained two medicals for that course. And so they usually don't have much capacity to train people, but they are pretty picky when they look through the applications. So they like to see that you have a good amount of knowledge within the sport. And then the other caveat here too is that sometimes some sports might have three classifiers or sometimes you might see like the chief classifier coming to the panel. I was chatting with my mentor earlier this week and she had said that BACHA, sometimes they have a physician, a physical therapist and a technical classifier. So there's a lot of variability within the Paralympic movement on how panels do this, but usually you should have at least one medical classifier and one technical classifier in the panel and they're evaluating the athlete in person. So within the Paralympic movement, there are three big eligible impairment categories. That's physical impairments, visual impairments and intellectual impairments. Within the physical impairment category there, and this is the most dominant category in the Paralympics. Most sports involve physical impairments with some exceptions, but we'll show you that later today. There are eight subcategories. So there's impaired muscle power, which is like permanent muscle weakness from maybe a brachial plexus birth injury or spinal cord injury. You have limb deficiency, which can be congenital or acquired leg length difference. And it does have to be a significant leg length difference. Again, this varies by sport. In Paralympic swimming, you have to have at least 200 millimeters of a difference. And then short stature. So that's like your achondroplasia or other skeletal dysplasia. Hypertonia includes all of your different types of high tone abnormalities that are permanent. So spasticity, dystonia, chorea, all of those things. And then ataxia, athetosis, and then impaired passive range of motion has to be permanent. So basically contractures from, you know, like arthrogryposis, or if someone has a contracture from spina bifida, spinal cord injury, what have you. So you have to have at least one of these to be evaluated under the physical impairment category. And again, it has to make sense with your known medical history. This is a diagram that just, this is an example table from an old Team USA website that is now retired, but this table still applies. And you could see a breakdown of all the different Paralympic sports. It's broken up between summer and winter sports. And at the top, the columns split up things by the type of impairment. And so you could see not every sport, in fact, the majority of the sports do not accept all of the impairments. Only Paralympic swimming and track and field accept all of the impairments. And then some of them only take one category of impairment. For example, goalball and judo are only for athletes with visual impairments. So there's a lot of variety and it's important to know this. And like also things, again, today we're focusing on the Paralympic movement, but there's a lot of different things outside of the Paralympic movement in adaptive sports too, right? And so it's important to know what resources are out there for competition so that you can refer your patients to the right places if they're interested in a specific sport. Okay, so we're gonna delve into an individual example. And again, paraswimming, I've learned, I'm biased, right? This is my main sport. It's very niche. It's very different from other sports. But that being said, other sports will probably say the same thing, that they're quite different from other sports. I choose to talk about paraswimming because I feel like it's one of the more complicated ones out there. And if you could understand this one, it'll be pretty easy to understand the other ones or learn the other ones. So in paraswimming for classification, what we do is we do a physical assessment. These are the categories of physical assessments. Again, not every athlete is gonna get all of these things. In fact, most of them don't get all of these things unless they end up having a whole bunch of medical stuff going on. We pick the assessments that make sense to do, right? So if they have permanent weakness from a spinal cord injury, I'm gonna do a manual muscle strength testing. So yes, we do manual muscle testing and nothing more fancy than that to test their strength. If they have any abnormal tone, we actually do coordination testing. Even if they have weakness, we'll do the coordination testing. Usually instead of the muscle strength testing, it's the coordination testing takes into consideration their strength. And it's this bizarre test. It's not like finger, nose, finger or rapid alternating movements that we, well, it is rapid alternating movements, but it's not like the same rapid alternating movements that we do in clinic. It's this rapid alternating movements exam where we have them go through different movements at each joint in different planes that are relevant to the sport of swimming. And so for example, we may have them lie supine and to check shoulder flexion extension, we have them raise their arm up overhead back and forth and then we have them do it very fast and we grade it on a scale of zero to five. So very similar to how we grade manual muscle testing, except obviously there's different criteria on how we grade it. It's basically graded on what range they can get and how smooth and quick they can move their movements. So it's a really interesting but bizarre test and quite subjective, just like manual muscle testing is also can be subjective. Then there's also passive functional range of motion testing. So that's when we get at our goniometer and it's very tedious. We measure a lot of things. The important thing to note here that I remember was very interesting when I was training as a classifier and I loved thinking about as a physiatrist and thinking about biomechanics is just because you don't have full physiologic range of motion does not mean that that actually impacts your classification in a certain sport. So for paraswimming, our denominator, which is our normal, our denominator is actually what's normal, what's necessary for the sport of swimming. So for example, in swimming, we don't use a lot of ankle dorsiflexion except for in breaststroke. And so when you're in freestyle or backstroke or butterfly, most of the time you're in plantar flexion. So if you can't dorsiflex your ankle past neutral, you're not going to lose much, if anything, or that's not going to impact your classification for the freestyle stroke, right? Because that movement, even though you do have an impairment there, that movement's not going to impact that. And so again, it goes back to the functions of the sport and understanding the sports necessities of the human body. For anyone who has a limb difference or deficiency, we do measurements of their limbs and then we calculate what percentage is missing. If they have a side of their body that's unaffected by the limb deficiency and is typically developed, then we will use that as the denominator. But if they are someone who, especially in our congenital population, have multiple limbs involved bilaterally, then there's an equation we use that predicts their predicted limb length based on their seated height. But again, we've also seen that that's not perfect because we've had some athletes who've later acquired, like maybe they had a unilateral BKA, and then they later acquired another amputation on the other side. And when we compared those measurements to what was predicted, it can be off, right? It's science, right? But science doesn't always predict what humans actually can do. So it's not a perfect system. Height measurement is our favorite one because it's the easiest one. And that's for anyone who has eligible short stature from things like achondroplasia or skeletal dysplasia. We just measure their height and easy peasy, straightforward, and that determines their classification if they're eligible. And then lastly, leg length difference measurements, that's the same category of measuring a limb deficiency. We just measure the difference in their leg heights. So we go from their greater... All of our measurements are based on anatomic landmarks. So for instance, in the lower extremity, we'll use the greater trochanter, the lateral knee joint line, and then the distal fibula as our landmarks. And then in the upper extremity, we use the acromion, the lateral epicondyle of the elbow, and then the distal radius as our landmarks. And so you can imagine that's not perfect either, right? Things sometimes shift with soft tissue. Also for some of our congenital or even traumatic injuries, what happens if you don't have those landmarks anymore? Then the book just says, well, estimate the best you can, right? Well, that's not giving exact measurements. Sorry, my dog won't leave me alone today. So after you're done with the physical assessment, that's typically done in a quiet room, and they are doing a bench test. Then we do the technical assessment, which is the assessment in the sporting environment. So in swimming, it's in the water, and there's multiple reasons why we do that. We take a look at their water safety to make sure, especially for a newer athlete, that they are water safe and that they won't drown. We also look at the environmental effects. So how does the water impact their stroke and their impairment in their stroke pattern? So for instance, typically, and this is not for everyone, but typically the water will make spasticity worse versus just for dystonia. Our athletes with dystonia, their dystonia, the water helps them a lot more. And so we make adjustments to what we saw on the bench test based on what we see in the water. The technical assessment's also important at that time of classification to assess what are the needs of the athlete for assistance? Does the athlete need assistance to get in and out of the water? How do they get off the block? How do they hold their starts? It's the same thing in track and field and other sports too. They look at different levels of assistance and start abilities. And then based on all the things we see in the technical assessment, they give them exception codes. So it's silly, right? Like for someone who has a right below knee amputation in swimming, we have rules where like your feet need to point out when you're swimming breaststroke or your feet need to be together when you're doing butterfly, different things like that, right? Like, or you need to do a two hand touch. But what happens if you don't have a hand or you don't have a foot, right? It's silly, but the officials have to look at so many different things when they're seeing competition. They don't always know what an athlete's impairment is and they don't have time to figure out what the athlete's impairment is, right? And so that's why the exception codes exist so that if an official gives them a DQ based on a certain rule in swimming, the computer will be like, well, they have this exception code, so we'll just nullify it because it does not apply to that athlete given their impairment. And then again, different things happen, right? So especially our neurologic conditions, sometimes they can fatigue when they're participating in sports or their movements can all be altered when they're in different contexts in the sport. And so there's modifications that can be made there. Although I will say that fatigue is a really difficult thing to judge and objectify in the classification process. And so it is not measured well for our athletes and there definitely is a disadvantage for our athletes with neurologic impairments. So at the end of all of that, the athletes are then allocated a sport class if they are eligible within the sport of swimming. And this is true for many Paralympic sports. Each sport class has a bunch of different athletes. Not everyone looks the same. So you may see athletes with a whole variety of medical conditions competing against each other. And so it does not mean that they have to have the same medical condition or that they look the same. And also, I mean, as we know as physiatrists, not every impairment or disability is as visible as others. And so the thought though, is that within each class, functionally, they are impacted similarly in that sport. Now, the other thing to remember is the opposite is true in that just because you have the same medical condition does not mean that you will go to the same class. So a good example there is cerebral palsy, right? There's a lot of wide variety of functional abilities within that diagnosis. And so again, it's just based on what their function looks like. And then also, sometimes you don't always know that, like maybe you know someone has cerebral palsy, you might not know they have some other impairments that they also looked at that were eligible to look at. In the sport of swimming, we use in this bottom left corner, you'll see a table. We use a point system and it's a continuous number system, but it's actually the classification is not actually a continuous variable. It's actually discrete category. So if you think back, like the analogy I always use is like our grading system in schools, when we were younger, you could use like the ABCDE or sorry, ABCDF grading system, or you can use the one that's more numeric, right? And so classification is still just three variables. They will get a classification S1 through S10, which the S classes in swimming is for freestyle, backstroke and butterfly. The SB class is for breaststroke. And then there's also a separate SM class for individual medley, which is calculated based on their S and SB class. But you can see here that this is that functional assessment that I just talked about with the bench exam and also looking at them in the pool, we're grading them throughout the whole thing. And then their points determine what class they go into. Okay. So you can imagine like the most familiar one, all of you guys know is manual muscle testing. It's a five point scale, right? We don't use pluses or minuses. And so that five point scale, like if you got full, you've got full strength everywhere, your fives everywhere, your score is going to be a 300 for the S10 and a 290 for the SB class. And so with that, if you're full, you're not going to be classified eligible. So you have to have a minimum of 15 points lost to get into the least impaired class in swimming. And then also a minimum of a 15 point loss from 290 for the SB class. And so it's a point scale versus if you look at some other sports like track and field, paracycling, other sports to this, they designate things more on a descriptive category assessment. So their first, they usually get a three digit sequence for their classification. So the first one is track or field event. The second is their disability category. So whether they have an intellectual impairment or a visual impairment or a coordination impairment. Um, so they are not able to, they would probably pick which one based on their assessment is more dominant because if you had like an amputation plus a coordination issue, right? Like some of my paraswimmers might have, um, you know, I have some veterans on my, my team, right? So they might have traumatic brain injuries plus amputations. Um, unfortunately with this system, it's more descriptive. You have to pick one or the other, right. Versus in swimming for some of our impairments, we are able to combine their points for that and take into consideration multiple, but again, it's not perfect either. And we'll talk a little bit about some of the limitations with classification later in this talk, but, um, we can't, you know, there is some flexibility in our point system to be able to factor in multiple impairments to a certain degree. Um, and then in track and field, that last number is their, um, their severity of their impairment. And again, it's not an, they don't use, they will, you know, they grade their athletes on different things. Like they'll use manual muscle testing, other things, but their, um, their assessment is actually more of a descriptive, right? So I've seen that their assessment for, to figure out where people go, they look at like, okay, are you a hemiparetic cerebral palsy or are you a quad? Um, or for spinal cord injury, they'll have different levels that they talk about and they look at their assessment on the exam. So it's more of a descriptive type pattern. Um, the last thing I wanted to mention for this slide is that, um, like I said before, classification has to be performed at an officially sanctioned event. And that's because the last step, um, is observation during competition. It used to be that they used to observe every single athlete in a competition. Um, I've seen a lot of classification to move away from this. We've moved away from this in swimming. Um, mainly because, um, if you know, they're not going to change in the water and you already know their water safe, we don't always observe them. Um, sorry, we do the technical assessment, but if you know that, if you, if you know that their assessment is not going to change in competition, for instance, if they have a baloney amputation, I know that they're not cheating the system. I know that they're, um, the way they move the stress of competition, it's not going to change their impairment and how that impairment impacts the water versus someone who has a neurologic condition. Usually they will observe them in competition because there's different factors in competition that could happen. Well, number one is they want to make sure you're not cheating, but it's also silly because they only observe you during the first, um, appearance, uh, for that stroke. And so, um, you know, if you ended up swimming that same event and another meet or later on in the meet, they're not going to observe it. And so it's kind of silly, but, um, right now the way they do it is they just observe the first appearance to make sure that what they're seeing in competition is consistent with what they saw during the actual classification process. And it's not just cheating, right? Like sometimes there's different factors that are impacted in constant competition. Sometimes they might see some things they didn't catch, um, during the actual classification process, but a good classification panel should be detailed and skilled enough to catch things that they're competitive that what they see in competition should be consistent. Um, and then again, each individual sport is very different. So we talked about swimming a lot, but every sport is so different with how they, they, um, they process classification for their athletes and how their athletes are classified. So moving on, um, so paraswimming were one of the sports that includes athletes with visual impairments, uh, for visual impairment, paraswimming, you have to either have an impairment of your eye structure, your optic nerves or pathways, or your visual cortex. And so what they look at are either visual acuity or your visual field. Um, and you have to have eligibility there. And so they assess that, um, those eye exams. And then for intellectual impairments, we have a specialized neuropsychology battery of tests that we use. Um, important to note for us, the impairment needs to be seen before the age of 18. So it can't be an impairment after, or oftentimes we see cognitive impairment after traumatic brain injury. If that happened after the age of 18, it doesn't count as an intellectual impairment that's eligible for Paralympics. And so a lot of times we see autism spectrum disorder or down syndrome. I will say we end up seeing a lot more autism at the elite level. And if you think about it, um, it's because, so in swimming, we only have one category for intellectual impairment. So anyone who has intellectual impairment just competes in that one category. So that category self-selects for those who are least impaired, right? So as long as you have that minimum eligibility criteria, as long as you're intellectually impaired, minimally for that sports, you can compete, but obviously you're going to, the ones who are least impaired are going to make it to the elite level, right? Because they're not as significantly impacted. And so I think that's why we see more of the high level autism athletes at the elite level rather than like down syndrome. So again, raises a question of like equity, equity and resources available for athletes. Okay. Um, oh, I think, okay. The last thing I wanted to mention is, um, classification with multiple eligible impairments. So I had mentioned previously that, you know, I gave you guys that example of track and field versus swimming on how do they handle multiple eligible impairments. So first off backing up, if you have a physical, a visual and an intellectual impairment or any combination of those three, um, you cannot get classified. You can get classified for each of those individually, but unfortunately the, to my knowledge and all those sports currently take into consideration all three together, there's no way to factor in all three. So automatically someone who has more than one of these categories, they're going to be at a big disadvantage to compete, right? Because the classification system does not allow you to get factored in for both of them. You have to choose one or the other. So again, you can get classified under all of these different categories, but you need to decide before any observation and competition, which one are you going to go with? And then you can request to change it, but it has to be at the end of a season or after the close of the Paralympic games and before the next season starts to decide which one. So you can't just flip flop and be like, okay, at this event, I'm going to compete under physical. And then this next event, I'm going to compete under visual. You have to choose on the season. Um, and then as I was mentioning before too, there's no, for some impairments, it's not possible right now, um, depending on the sport to factor in, um, there are multiple eligible impairments. Um, one example there is I'm trying to think, um, if you have short stature and then also, um, a strength issue. So one of my athletes with achondroplasia on paraswimming, I just diagnosed him with a thoracics and cervical cord syrinx. Um, and he has weakness that he's had there for a long time and we finally found an eligible medical condition for it, but he had to lose a minimum of, uh, 25 points to drop down to the next class. So even though he had weakness there, and then only two classes were short stature and paraswimming. And so even though he has weakness there that impairs him more, he didn't have enough weakness to drop him down to the next class. So unfortunately it's not factored into, you know, his, his, his classification. Okay. We're going to delve into team sport classification. This is a lot faster because that individual sport classification, that's a lot of the foundation here. And again, my caveat here is that, um, every sport is different. Um, but many of the team sports will use a point system and then, um, basically they add up the number of players. Like let's say you're allowed, you know, X number of athletes on the field of play, right? The X number of athletes, when you sum up all of their classifications, they cannot exceed a certain number of points. And so that depends on the sport. So we're going to use the example of wheelchair rugby, um, in the sport of wheelchair rugby, um, you cannot have more than eight points cumulative on the field of play at any time when you look at all of your athletes together. Okay. Um, there, this is their list of eligible impairments. So like I talked about before, you can see, um, it's mainly physical focused, uh, you know, I should just have Johan speak on this, right. But, um, anyway, uh, you know, they don't include athletes with visual impairment or intellectual impairment and that, you know, it makes sense, right. Because when you're dealing with a team sport, there's some more nuanced things, right. That makes it more difficult when you would have someone with, with an intellectual or visual impairment, um, it presents a lot of challenges. And from a medical perspective, I'd be worried a lot more about injuries or other things, right. Um, but you know, I was talking to my mentor about this earlier this week, and you know, this is not exactly true for every team sport. He participates in Paralympic curling and in curling, they don't use a cumulative point model. They have four people on the field of play at all times. And they don't, um, it's basically you're eligible or you're not, um, to go on the field. And so, um, again, this is take this with a grain of salt, but this is, I think the example that most team sports follow. The other thing I want to mention to you is just because some individual sports are classified as individual, right? Like Paralympic swimming is an individual sports. We do have some team settings right in the sport. So we do relay. And so when we do relays, we follow this model as well, where you can't have more than a certain number of points cumulatively for all of your, um, athletes classification classes. And so in wheelchair rugby, um, their example here is you have, um, these, uh, seven categories for classification and a 0.5 is, um, those athletes that are most impaired and a 3.5 is least impaired. And so based on your impairment, you're going to have different roles on the field of play, which makes sense, right? Because it just depends on how, um, what your functional abilities are in that sport. And so those who are more impaired, tend to be more of like a defensive blocker versus someone who's least impaired. We'll end up handling the ball a lot more and they get, they have a lot more dexterity. That makes sense. So the last thing I want to talk about before we start going into controversies is when to get classified and where to get classified, because I think this is the most relevant for our general audience. For most physiatrists, you're going to, you're going to at some point encounter someone who you want to refer to the Paralympic movement. And so it's important to know when to send those athletes and say, Hey, you should think about getting classified. So truth or myth, what do you guys think? Athletes with disabilities should not get classified until they are ready to compete at an elite level. I'll let you guys think about that for a little bit. So this is a myth, right? Um, so really anytime an athlete is ready to go into undergo competition is when they should get classified. Um, but before that they need to be, just because they're ready to go into competition, they should first make sure they've tried the sport out and that they can successfully perform the sport. Um, so I've seen some athletes, especially in swimming, like it's, it's a concern, right? Because we want to make sure they're water safe and not going to drown. Um, but you know, in any other sport, you want to make sure they've learned the basic skills first before they undergo classification. Because that classification process is going to look at their skills in that sport. So they need to have some basic knowledge about how the sport works first before they do it. Um, so when they're, once they're interested in competing in sport, does that have to be in an elite level? In fact, anytime, like they're starting to think about competition, you want them to undergo it because that helps them set up like, okay, what are my goals for that sport? Right. Like in swimming, they're going to have, they're gonna have no idea what times they should be working towards if they don't know their classification. Right. So that's important to help, um, get them set up with early on when they're considering competition. There is no specific minimum age for classification in the U S but internationally, um, There might be some parameters. It just depends on the sport. Some like make a cutoff of 18 years old, but some, you know, you see, we've definitely seen younger athletes compete at the Paralympic games. Right. So some sports, um, I think I have a cutoff of 12, but again, it just depends on the sport. Um, national classification needs to become first before international classification. So you need to get classified for a U S event before going classification, going undergoing classification for an international event, and then I talked about that already. Um, you need to be able to follow instructions and be actively engaged in the classification process, um, at least for the physical and visual, um, impairment category for intellectual impairment, they've got their battery tests that. You know, assess how well you follow instructions and it can engage, right. But for the physical and visual impairment, as you saw, they need to follow some instructions that we do. Um, right. Like when I'm checking manual muscle testing, I'm a pediatric physiatrist. Sometimes I can't check manual muscle testing in my really little eight of anybody kiddos because, or my, uh, my patients with certain intellectual or cognitive impairments, right. Because they don't understand how to do the position or do the movement. Right. And so they need to be able to follow those instructions so that we can classify them properly. And then whenever there's a medical change impacting their function in this sport, um, again, this is an honor system thing, but they are required to report that. And then, um, if it's a significant, um, impact on their function, then they have to undergo review in their classification and then all athletes, if they've been classified before they were 18, they get classified again after they're 18 and that's more because of, um, the skeletal maturity aspect, um, as we know. Um, In pediatric rehab, you know, cerebral palsy is a stable diagnosis, but your spasticity can change quite significantly when you go through growth spurts and that may change your risk for contractures or other things. Where do you go undergo classification? So this is very, um, Dependent on the sport. Um, I will say the biggest places to look are, um, the Paris sport national governing bodies website. So for instance, for wheelchair basketball, I would look at the NWBA website for Paralympic swimming. You would look on the Paralympic website there, um, but move United. Oftentimes we'll have a list too on their website. If you look at this, um, so this is a snapshot of their website. If you look under the events page, um, there's a section that talks about sanctions competitions, and usually they'll list us a list of sports and you can get an idea of if they're going to offer classification or not, but if it's not listed there, you can also contact someone at move United. Sometimes they may not know until like a month or so outside of the event, because they still may be working on recruiting a classification panel. Um, but oftentimes they do know months in advanced. So, all right. So what are some of the controversies and what are future directions for Paralympic classification? And I kind of, uh, the way I talked about things today alluded to some of the weaknesses within the system. So as you can see, that brings up a lot of controversy. So, um, you know, the way I look at this is the equivalent in the Olympic movement is doping, right. And cheating. Um, and it's a clean sport issue. Um, if we don't have a sound and, um, a very strongly evidence-based objective classification process within the Paralympic movement, this is a clean sport issue. Um, because once you're getting to the elite level, but even at lower levels, right, like there's, there's gain to be had from, um, um, being classified lower or having more impairments or having different medical conditions. Right. So it's like the opposite of what we deal with in the medical field. Right. Because usually our patients are devastated, uh, when they have a medical diagnosis and the Paralympic movement, you know, someone who's normal would, would feel that way. But I will say I've definitely encountered some athletes who are happy to get another diagnosis. Right. Because for them, they're like, oh, this might impact my classification so that I can have our lower classification, which therefore means I will be more competitive. And then maybe I'll be able to medal. I have a more upper reputation. Um, their identity as a Paralympian is impacted, right. Or, or Paralympic athlete is impacted. Um, and then also, you know, in Paralympic swimming, we get, um, if you are on our national team at a certain level, you get a stipend, um, and some of our athletes can just survive, um, on the money they make from making medals and making our national team. And so there there's a lot of gain to be had. So don't be fooled by this. I think. Unfortunately, I've seen athletes come to classification and they just find a doctor to write down some type of medical clinician. And they think like, oh, Paralympics, this is great. We're getting them involved in sport and to a degree. Yes, we do want our athletes. All people with and without disabilities should have the opportunity to participate in sports, to participate in physical activity and exercise. However, we also need to do a lot more education on, we can't just be handing out diagnoses to people. You need to have objective evidence that someone has a certain diagnosis and not agreeing to document it unless they truly have that. Um, and so there's a lot of, uh, controversies that have come up on people, cheating things. Even if you have an eligible diagnosis or impairment, sometimes we worry that people are exaggerating their diagnosis on the day of classification. Um, you know, there's stories. If you look in the meter, there's tons out there, but there's stories about, um, some countries coaching their athletes to take a cold shower to worsen their spasticity before classification or going off for their medications, right? Um, and so, you know, this is really important, uh, when you look at clean sport in classification. So we need a lot more research, um, to take a look at classification processes and make sure that we're measuring things objectively, right? Because the things I mentioned to you guys, it's not very objective right now. Like I mentioned, even with, with like measuring limb measurements, I told you we were measuring them based on anatomic, uh, landmarks. Why are we not using x-rays to, to actually make more precise measurements? Right. And I get it. It's because the x-rays, when we do precise measurements there, it's only measuring the bone. There may be some impact of the soft tissue, right? Like the soft tissue has more soft surface area than the bone. So that, that may be why we don't look at that. But again, it's not an exact science when we're using just anatomic landmarks. Uh, same thing with manual muscle testing or that coordination test I described to you guys, right? It's very subjective and also very easy to fake. And so that's where it really, I think I talk about this with my mentor quite a bit, and of course we're biased, right? Because we're all physiatrists here. We're all physicians. Um, and for sure, I think there's many great physical therapists out there, but physical therapists oftentimes, you know, with, with a rare exception, oftentimes they don't have as much medical expertise in terms of a diagnostic aspect, um, that a physician, like a physiatrist would have to be able to translate, okay, I know that they have a lesion here in the parietal lobe. So therefore I should see this deficit, right? Like being able to translate the diagnostic findings to what we should be seeing on the exam. Um, and so I think there are a lot of times that, and I've seen this, at least in Paralympic swimming, that athletes are classified based on what they see on their exam without necessarily taking into consideration. Like, does that make sense with their diagnosis? Should I be seeing that much of an impact? Um, another example is I had an athlete that classified for review a few years ago, um, who has bilateral club feet. And I told them, I was like, look, I'm only allowed to score your ankles and your feet. I can't look at anything else because technically your strength, even though you have weakness and I'm, um, you know, more proximally in your hips and your knees, and I recognize part of that is because you have not, you know, you're at a disadvantage with training because of your club feet, technically that's, that's trainable and you just need to be training smarter rather than harder. There's other ways you can train. Right. And you know, that, that athlete, her father is a physician and got really upset with me. And it's like, well, the last classification panel looked at, looked at her hips and I was like, I'm sorry, they were not supposed to, because that's trainable. And she doesn't have an eligible medical condition that causes permanent weakness in her hips. Right. She just has club feet. And so, you know, I think, um, there's, there's a lot to be said that there needs to be better quality and consistency across classification panels as well. And certainly if you get more experience in this realm, you'll see there's a lot of variability and the athletes pick up on it fast too. The country's picking up and they're like, oh yeah, you don't want that classification panel. You want that one, right. Or like more, and it's not necessarily because one's easier than the others is because they also, like, I know for us, like when I travel with our athletes as team physician, I go in and I audit their classifications internationally, and so I'm not allowed to be an international classifier for Paris swimming because I have my head team physician role as a conflict of interest. Uh, but I go in with all of our athletes to their international classifications because with my classification background, I know whether they're doing the classification properly or not. And I definitely see variability in the assessments, simple things, even like testing knee flexion strength. And they don't put them in an anti-gravity position. And I have to say something to them, right? That that's just very basic. Um, and so, uh, there's a lot of variability there, but then for me, when I'm traveling with our athletes, I worry about what classification panel they're going to get, because I want to make sure they have a panel that knows what they're doing and not one that I have to like put up a lot of fights and like have to protest later on, because I don't think what they did was correct. So there's a lot of controversy. Um, other, other controversies. Um, so I mentioned this previously, we look at categorical or discrete variables rather than continuous variables, but again, I don't know if we necessarily can go to continuous variables either, because the continuous variables in swimming, we have, you know, a 25 point range with teaching within each class. Um, you will, you'll see that, um, there's fluctuations impairment, right? Like for instance, spasticity or dystonia is a great example. Under stress, there's spasticity or dystonia can get worse, right. Or cold weather or if they're sick. Right. And so it fluctuates or even without all those things, it can fluctuate day to day. And so the current system allows that fluctuation, but what do you do when someone's like right on the border of one versus the other, it's always a hard decision to either bump them up or bump them down, right? The athlete, of course, always wants to be bumped down in most cases, but that doesn't always happen. And then it puts people at a disadvantage. And then you will always with this discrete variable categorical system, you will always have people who are the cream of the crop least impaired within each category. And there raises a question of, well, then are we, we're biased towards those who have less impairment and now they have a slight advantage within their class. Um, another issue is that if an athlete does not have a known definitive diagnosis, um, for an eligible impairment that they have, they cannot undergo classification until they have that definitive diagnosis. And so I, you know, I talked about that previously about making sure they have the proper tests, but sometimes our medical. Testing and our medical technology is limited in itself, right? I have so many conversations with my patients just because I see so many rare conditions or rare things. I tell them, I'm like, look, just because we have not found anything positive right now does not mean that you don't have something going on. It's just that our medical system right now is not smart enough to figure out what you have. Right. And so that, that really stinks for those athletes. I mean, I think this is the minority, but that really stinks for those athletes who still are undergoing workups and may never have a known diagnosis, um, obtained until later in life or at all in their lifetime. They can't compete unless they have a definitive diagnosis. Um, but. The caveat to this too, is that we need to make sure they have a definitive diagnosis because it protects the integrity of the clean sport competition system. Um, and also, um, make sure that it's a diagnosis that is treatable or can improve over time. And the example there I gave before was functional neurologic disorder, right? They can look very disabled, but that's something that definitely can go back to normalcy. Uh, we talked about, let's see. Um, Oh, okay. So athletes who have an eligible medical condition or impairment, they still might not meet that minimum impairment criteria. And so that really stinks because like I showed you guys, the example for Paris women bank, you have to lose a minimum of 15 points in each category from what is normal. Um, so if you only lose 14 points, you are not eligible enough. And so they say you're not quote unquote disabled enough and you should be able to compete against able-bodied sports, but we all know they're still at a disadvantage compared to those, to those who don't, who are typically developed. Right. But that being said, I think, you know, when I play devil's advocate there too, it's like, well, you know, in able-bodied sports, there's a lot of people who have other medical conditions too, that are not like Paralympic eligible, right? You might have a thyroid, um, disorder, or you might have, um, ADHD, you could have, uh, asthma or respiratory stuff going on and that puts you at disadvantage too. So there's a lot of different things that we, you know, you can't just, not everything is going to be able to be considered in the Paralympic movement. Um, and then I talked about the issues right now, the weaknesses with not being able to cumulatively factor in multiple eligible impairments in some cases. Um, the other tricky thing too. So how do we stop athletes from exaggerating their impairment or functional impact in sport? Um, so an example there is like, maybe they have a brain injury and they have coordination issues, but how do you know, like how bad their coordination impairment should be, right. Or someone who has, um, you know, impaired strength, that's a spinal cord injury, but it's an incomplete injury. How do we know they typically should have two out of five strength versus three out of five strength. Right. Um, and then the other question there too, is what happens if they have an eligible impairment, but they have like a functional neurologic disorder or functional overlay on top of their no disorder, how do you distinguish them and what's eligible and what's not, and how do you pick those apart to score them properly? Right. And you can argue that, you know, someone who's very skilled medically should be able to have a good physical exam to discern what's coming from what, but sometimes it's not that easy. Like what happens if you have an athlete who is like a really weird general genetic dystonia disorder, and then they've got functional neurologic disorder on top of that. Like there's, you know, there's nothing from a medical testing perspective to tell me, well, she should only have dystonia with this movement and like this much dystonia. Right. Like we already have a hard time objectifying dystonia in our regular clinical practice. Right now throw FND on top of that. How do you distinguish those? And, you know, you could say like, okay, like you should be able to pick out inconsistencies with FND, which is definitely something we look for, but, you know, we see these guys over such a short snapshot of time too. You don't always have time to see all the things going on with them. And so, you know, it raises the question of should more longitudinal assessments be performed, but then when you do more longitudinal assessments, that also takes up a lot more resources that the Paralympic movement does not have. So these are some areas I've, I've thought about for classification that needs to be optimized. Like I mentioned, there needs to be more objective measures. And so with that, we need more research to take a look at that. And then also what about eligible diagnoses or impairments that are not as easily measured, right? So the biggest example that everyone always brings up in the Paralympic movement is fatigue. There's pathologic fatigue and physiologic fatigue, right? And so pathologic fatigue is something that a lot of our patients and athletes with neurologic conditions battle with because they don't have normal neuromuscular function or recovery. But that is currently not factored into how they are classified. And that's unfair because as I showed you guys in that little slide that showed you the class, you can have someone with cerebral palsy competing at someone with just an amputation or just a contraplasia, like an orthopedic issue that doesn't have pathologic fatigue, right? So technically during your short snapshot of evaluating those athletes and classification, you saw what, how their impairment impacted them in sport, but you did not watch entirely how that fatigue was factored in and you're not able to factor that fatigue into the classification process. And so it does put them at a disadvantage as well. And then the other thing I want to note, something I've realized as a head to position is that our athletes with more severe impairment, they're still expected to go through the same processes for classification as our athletes with less impairment. And that includes the amount they have to swim. And oftentimes they often have to swim more in their technical assessment than those with milder impairments because they tend to be more medically complex. But that again, going back to fatigue and going back to their neuromuscular system and their pathology, it impacts them a lot more medically. They have to spend so much more energy. And so then their recovery after classification, they're so stressed that day. I have an athlete with generalized dystonia from this, and she goes, she gets into dystonic crisis almost every time now. There's also with the more medically complex athletes, oftentimes classification is not straightforward. So they undergo a lot more protests. They also, for athletes who have either progressive medical conditions or recurrent relapsing conditions, they have to undergo review every couple of years or every year, depending on what, how severe their medical conditions are. So that can be very taxing on their bodies as well. And do we need to think about other considerations for classification that still allows fairness, but allows these athletes to be assessed in a more medically safe and welcoming environment? Like, do we consider classifying them over two days instead of one? So they're not, they're not as exhausted. Right. But again, this becomes a resource thing too. And if you're requiring, you know, an athlete with a more severe impairment to be classified over two days, then, you know, now they have to pay for more time traveling. And that may, you know, two days may not necessarily be less stress than their body either, even though you're spreading it out. Now they're like, oh my gosh, I have to think about two days classification because they're just one. Right. So there's a lot of different things that are not perfect with the system and need to be optimized. And so, you know, things that I want you guys to think about too with classification is not just about getting athletes into the right class, but also this impacts their access to opportunities and resources, right? Like, think about that athlete who didn't meet that minimum eligibility criteria for that sport. They've just lost a lot of opportunities for sport identity, for growing a career in sport and finding, you know, I think a lot of times our Paralympic athletes cherish their opportunities in sport because it allows them to feel a sense of normalcy that they don't get in the rest of society. And, you know, you, as physiatrists, we know that society needs to fix that, but, you know, in the meantime, sport provides that. And when you say that someone's not eligible enough or they're not, they're not impaired enough to drop down to the next class or they're not competitive enough, it impacts them quite a bit psychologically and socially. And then the other thing that's an issue here is that you will read a lot of media articles about the controversies about suspecting cheating. The concern there is that, so unlike in the Olympic movement, where like if someone's cheating because of doping, it's like clearly easily able to be tested and you can also publicize that, right? For the Paralympic movement, it's really hard to prove someone is cheating, especially if you don't know their medical history and their medical history is protected by HIPAA. And so you can't just, you know, not everyone, just because you think you know their medical history does not mean that you know all of their medical history. And then there's also a lot of mental health impact on classification, not just on the classification process on the individual athlete, but also other athletes too, right? So when you have a teammate who is getting classified or undergoing classification review or new athlete you're watching from another country get classified and you're wondering are they getting classified fairly, are they getting classified correctly, and they end up in your class, that impacts your mental health as well, right? Because you're wondering like, you know, are they going to mess with your competitiveness in that sport as well? And so there's a lot of psychosocial aspects here and then that's why there's a lot of bullying. I know in paraswimming we've seen a lot of bullying among athletes too about classification or even some of the athletes don't want to, even though they should be dropped down to a class and I've seen them and I'm like, yeah they did the classification correctly, you need to drop down to class. Some of my athletes have been like, I don't want to drop down to class because I'm worried about what the other athletes will say, right? And you're like, oh my gosh, like it's just like a system where you feel like sometimes you can't win because sometimes athletes are upset that they didn't drop down to class but then they're like, well I didn't want to drop down to class anyway because people are going to bully me if I do, right? And so it's a very weird system and it brings up a lot of unique challenges that the Olympic movement doesn't help with. So if you end up taking care of any athletes as a team physician, as a medical director, these are some things to think about. So what are the medical implications or risks that can happen and how do you prevent adverse events? Most athletes, as I explained, find the classification process very stressful. So you want to make sure they have enough time to adjust to jet lag, recover from travel, acclimate to their environment. And so especially for international classification, think about where are you guys going, what does the environment look like, what's the time zone difference. Make sure you also provide them with a lot of time to recover, and this is again variable based on the athlete. But oftentimes you want to encourage athletes to cool down after classification or take some time off from practice, maybe take a day off from training that day because it's a very stressful process. And then there's also, I had briefly mentioned, there is a protest process for athletes where if the, and anyone can protest it from the team. So the team, when I say that, it can be the team lead or the athlete or the medical professional. It's usually not, I don't think like another athlete can protest it, but you can go through, if you feel like an athlete did not get classified properly, that athlete can, that athlete and their support team can protest and the International Federation will review that protest. And if they think it's, if you cite the proper rule book definitions and protocols, and then you provide sound reasoning as to what you felt was not performed correctly, they will put that athlete through a protest process where they have to get classified all over again. It's a whole process that's done by a different panel. And technically that panel should be non-biased and not talking to the other panel so that it's a completely individual process that's non-biased and it's fair. But for, especially for athletes with more severe impairment, you need to think about, well, what is that, how does that impact them on their health, on their performance, on their competition, on their recovery, right? And so I always have a discussion with my athletes and I tell them, look, like this is where I feel like they didn't do this correctly. However, one, I'm not going to protest it unless I think it's going to make a difference. But two, I also have them, it's a shared decision on whether or not we protest it or not, because the athlete needs to also know the risks if they go through protests. And again, the other risk too, is that we go through the whole thing and that next classification panel does not change it, or sometimes they might class them up. So it just depends. Everyone's different. And I always share those risks with my athletes. How to prevent future adverse events. I prepare my athletes. I meet with most of them before they undergo classification or classification review, so that I make sure they have submitted the correct medical documentation. So they also make sure that they're prepared for what the process will look like. And sometimes there's a lot of issues right now. We've been pushing for more transparency with classification, but there's a lot of misunderstanding on what classification actually does. And like, when a classifier asks a question, sometimes it might be the most benign thing that you say, or the most benign question, but that athlete doesn't understand why you're saying that or why you're asking that. And you might be just trying to make small talk, but they're like, oh my gosh, whatever I say for this is going to impact my classification. And so I do a lot of counseling with our athletes to clarify what actually matters for classification. What information do they need to make sure they can make clearly about their medical history, about making sure they're cooperating fully and honestly, and what things, what types of physical exam testing they may undergo. I do think there is benefit in having the team physician role go in with athletes and support athletes. But recently I chatted with my head team physician partners over in the UK for British Paraswimming. And it's interesting there, they say they have, they don't want to do anything with classification. I can understand their perspective too of that. They feel that if they were involved with classification, there's a boundary crossing there a little bit too of like the athletes. There's concern that the athletes may not be fully upfront with you about their medical issues because they may be afraid that may impact their classification. But for me, I tell my, I tell our athletes like, look, I don't have, I don't necessarily have a say in your classification, but I can advocate for you. If I feel like things were not done properly or making sure things are done properly. And so I don't think I've had that issue for the majority of our athletes, but there have been some where I, I think it's mainly the athletes that are trying to hide something or not fully being honest. They may try to hide things for me from a medical perspective, and then that might impact my medical assessment of athletes in my team physician role. And then I think it's really, I've done meetings with our whole team and presentations to kind of incur, I do a lot of talks about transparency, about classification and what it is, what it is not, what are the limitations with the system? And we encourage camaraderie across the team. You know, I think that that's been hit or miss on whether it's actually achieved the goal of clarifying some of these myths about classification. I think athletes and families will just believe what they want in classification, but I think it's helpful with some of our teammates. And then the last thing is having them as we are physiatrists and we're really great with this, having a multidisciplinary approach to surround our athletes to provide the best support that they can have. So other ways medical providers can be useful when it comes to classification, be at least familiar with your sports classification process. This is more for if you're a team physician or medical role, and you can participate in formal training process if possible in your sport. Sometimes it's not possible until they offer it, right? So for paraswimming, we haven't offered it since 2017. So we're waiting for the next course to happen. Again, I mentioned that we chaperone athletes into the classification process and we advocate for their needs. And then you can serve as their medical liaison. I help, I consult with a lot of our athletes remotely over Zoom before their classifications to make sure they've gathered all their partner medical information. An example there is like I had, you know, that athlete with achondroplasia I mentioned earlier, they had mentioned for years they've been having weakness in their arms and their legs. And before I was in Colorado, I sent that athlete to an outside physiatrist and I explained all the things as to what that athlete was experiencing and the importance of getting diagnostic testing. And unfortunately that doctor decided, well, his weakness is only mild. I don't think we need any further workup. And I think that physiatrist also didn't understand a lot about achondroplasia or hyperchondroplasia and the medical risks there. So finally I asked that athlete, I was like, do you want to see me? And he for a while was putting it off. And then finally this year, he came to see me in my Colorado clinic. We got further diagnostic testing and we found that he had that syrinx in his spinal cord. And so it's really important to listen to your athletes, think about things holistically, but also understanding their underlying medical conditions and what can be risks for things that they can sustain and being very thorough with your physical exam. So take home points, classification varies by para-sport and aims to ensure a fair and level playing field for all competitors, but it's still evolving and further evidence-based research is needed. It's important to recognize that classification impacts para-athletes in many ways, physically, psychosocially, and the role of the multidisciplinary medical team is really important in supporting your para-athletes when it comes to classification. So for anyone who's interested in training as a medical or technical classifier, here's a QR link. Caveat here is this is mainly for the sports that are managed by the U.S. Olympic and Paralympic Training Center. This is not inclusive of all Paralympic sports. An example there is the wheelchair basketball sport. They're managed by the National Wheelchair Basketball Association. And so they are not under the USOPC umbrella. And so they have their own signups on their own websites. And then the other caveat here too is I would sign up for as many different sports that you are interested in, because you never know when a classification training will next be offered. And in which case that may not, you know, sometimes your first choice for it may take a long time to come up. And so I would sign up for any that you are interested in. Thank you, Stephanie. That was an awesome lecture on classification. I hope everyone took something out of that. It was super thorough. And so what I wanted to do since, you know, I want to be considerate of everyone's time, I have questions. We have probably have time for just two or three questions. If you have a question, feel free to put it in the chat. If you have a question, feel free to put it in the Q&A box. And I'll be happy to answer any questions that you might have. If you have a question, feel free to put it in the chat or raise your hand. And I'll just start off with one question in the meantime to give you guys some time to think of anything. So one question, you know, that I had was, can you elaborate a little bit about some of the research that's currently going on in adaptive sports in regards to classification and different types of ways we're trying to make it more equitable, et cetera? Yeah. I'm most familiar with what's going on in Paralympic swimming. And I will tell you, if you do a literature search, it's quite underwhelming what is there across not just paraswimming, but multiple sports, right? Sean Tweedy is the biggest name out there that you'll see for Paralympic classification research. He's a PhD and he does a lot of looking at, you know, athletes in the lab and everything. In paraswimming, there's been some studies more recently published on how to create a more evidence-based and quantitative measure of coordination deficits. And they've been using a lot of tapping measures to measure like how fast can you tap something, but it's very preliminary right now. It's not even like movements that are relevant to the sport of swimming. Like it's just like tapping on a table and like, yeah, that's like weekly involved in swimming that movement, but they have not gone that far yet. There's, I think, I'm trying to think, you know, in swimming, that's like the main thing they've looked at. I see Pam Wilson's on here, which, you know, Pam should have done this talk. Pam, do you know of any other research that's going on in Paralympic classification right now? Hey, Steph, how are you? Good. How are you? I'm good. Hey, thanks for doing this talk. The trend towards classification is really to standardize the process across the board and make sure that everybody's being examined equally. There's several studies, like I actually was involved in one study that was a Delphi study that was looking at coordination in the CP running athlete. And there are, you know, we looked at a bunch of different types of athletes, and there are, you know, we looked at a bunch of different stuff, and it was finally kind of streamed down to which tests were the best ones when you specifically were looking at coordination and running. The move is here is to look exactly at how the biomechanics affect the sport itself. So I'm going to give you an example is if you look at an amputee, a below amputee is only currently doing the one through 400. And that was because they looked at the starts, and the starts were impacted by the level of amputation. But when you looked at longer distances, it really only had a very mild impact on the running biomechanics. So, you know, they ended up using that information to change the classification system up a little bit. So there's lots of stuff out there. But, you know, it's the same as everything else. It's funding, it's time, it's everything else. So, you know, good times for people to get involved in research in this area. Yeah, it's really hard to find funding. And like Pam said, too. So Pam, I think I mentioned in my talk, but Pam's my mentor. I've learned a lot so much from her classification, which is why I say she should have just done this talk. But see, you know, I think funding is a big issue. And then also, like, you know, who, like, there's such a niche area, right? Like of who actually does research in this. But hopefully more people are getting interested in doing research in this area. There's one, I know, like I had access to a really fancy swim flume when I was in Dallas. And I had the opportunity to partner with one of our researchers, who's a sports cardiologist for NASA there. He's well known, Ben Levine, he created the Levine protocol for Ehlers-Danlos. And he's been like, asking me, like, I get emails from him every other month, like, hey, Steph, like, do you find funding yet for our potential study? Because we want to look at our athletes in the swim flume, and take a look at them at different velocities at different temperatures and take a look at their movement patterns with a camera to measure movement. But I also think like looking at like water displacement and other things, too, to take a look at what are things looking like in the water versus the bench, because I have not seen any studies like that yet. But again, it's, it's been hard finding funding. And I've tried like going the, you know, I tried contacting anti-doping funding sources for like clean sport, because I'm like, this is a clean sport issue, but they haven't, they haven't taken a bite. And then Holly, you put a question in the chat, if you like, you can feel free to ask, or I can do it for you, if you like. Yeah, I'm curious the spread of athletes by global representation, because there's significant variation of access to resources for adaptive sports in low-income countries, and if you're aware of any programs to increase representation. Yeah, and what do you mean by programs to increase representation? So do you mean like, like improving the number of athletes from, like increasing the number of athletes from those other countries? Yeah. I am not aware of anything. I know that it's funny. And Pam has much more experience than I do in this, right? I'm a lot younger than Pam in the, in the, in this realm. But, you know, when you go to the Paralympic Games, or big international Paralympic events, it's interesting, because I, I feel like in the US, we think we have all this technology, and then I go abroad, and I'm like, what are these, like, what is, what are these equipment, or this technology that these other countries have? And you realize how behind we are in terms of disability, too. I don't know. I mean, one, I think there is the fact that, I think that the incentive there is that if you medal, there's financial gain for the country, right? So I think most countries will recognize that, right? Because, and especially since now the medals are made of equal value to the Olympic medals, because they used to not be. And so the, so for those who don't know, when you get a gold, silver, or bronze medal at the Olympic and Paralympic Games, you get a certain stipend. But back in the, what was it, I think like five years, up until five years ago, it was, the Paralympic gold medal was one-fifth the value of the Olympic gold medal. So they finally changed that, right? And I think that has hopefully incentivized countries to recruit more athletes. But I think it's very variable on how per, how countries recruit their athletes. And here, I will say in the U.S., we are not perfect at it either. It's growing. There's a lot of talks about creating pipelines and it all starts at grassroots levels at local areas, right? Because if you don't have opportunities locally and regionally at lower levels where kids can get involved, they're not going to have the, it's going to take them a while to develop skills to be able to get to that elite level, right? It's very rarely that you have an athlete that's just naturally talented overnight that can make it to that elite level, right? Oftentimes you have to train athletes. And so I know in the U.S., they've been working on developing a lot more programs at grassroots levels. Move United's been a big component of that and sanctioning events and helping to provide insurance for different events so that people can post these different events around the country. I am not sure what other countries are doing. Yeah. I think it's an interesting question. So Steph, I'm going to just chime in on this. Yeah, go ahead. Yeah. So your question is actually a great one because there is this disparity among athlete types in different types of countries. Like if you go down to South America and some of the African countries, the technology for wheelchair sports, track chairs and stuff is actually lagging very, very far behind. So there is a move, especially through like the World Health Organizations and also the World Parasport Group, is to do outreach to these communities to help them develop coaching and help them develop an infrastructure that will bring programs into those areas and bring their level of athletes up. So, I mean, we know that this is a big problem, but there are people that are moving into those areas to try to, you know, meet some of these disparities we're seeing. Yeah. Thanks, Pam. The other interesting thing there too is like I've heard, I think it'd be interesting to look at like how different countries recruit people because I know like in paraswimming for a while, I don't know if they still do this, but Mexico would just pick up people on the streets that they saw who were struggling with disabilities and they're like, we're going to give you a home and we're going to help train you for different Paralympic stuff. Right. And so we like in Mexico, like we see a lot of the more physical impairments from Mexico in paraswimming. And I think it's partially because of their recruitment tactics. But yeah, thanks Pam for sharing that. You know, I think that's great that the World Health Organization has placed that initiative. Well, thanks again, Stephanie, for the lecture and Pam for chiming in here at the end with the questions and helping out. Thanks again for coming and thank you for AAPMNR for hosting us once more. And like I said, please keep an eye on this forum, emails, etc. for more information about us as we try to keep trying to make the adaptive sports community and movement continue to grow. Have a nice night and make sure you join the other member May communities as well.

Paralympic sports

classification

fairness

athletes

impairments

eligibility criteria

assessment

goal-setting

national classification

controversies

cheating concerns

biomechanics