Table 1

Non-exhaustive summary of current knowledge of impairment-related considerations, and corresponding applied practical recommendations for challenges associated with elevated altitude, cold temperatures, travel and jetlag and athlete health and safety at the 2022 Beijing Paralympic Games

ChallengeImpairmentSpecific impairment-related considerationsApplied practical impairment-related considerations during the paralympic games
AltitudeSpinal cord injury (SCI)
  • The central nervous system and respiratory system are affected in athletes with high-level paraplegia or tetraplegia, which may diminish the ability to adjust to altered barometric pressure (Theisen71).

  • Data have shown that athletes with neurological impairment report a high rate of acute mountain sickness (Kamaraj et al72)

  • Plan for prolonging the period of altitude acclimatisation.

  • Careful monitoring of acute mountain sickness.

Cerebral palsy
  • Physical performance may decline, and fatigue increase especially in athletes with more severe cerebral palsy (Dodge73).

  • Cognitive impact on pacing awareness can be particularly challenging when competing at high altitudes (Runciman et al74).

  • Careful monitoring of load during training, competitions and daily life, increased recovery may be needed.

Limb deficiency
Visual impairment
  • The magnitude of thermoregulatory limitations is proportional to the level of injury

  • Athletes are predisposed to hypothermia due to (Handrakis et al75):

    • Disruption of the autonomic nervous system and sympathetically induced vasoconstriction absent or delayed.

    • Reduced ability to generate body heat by shivering due to lack of motor control of skeletal muscles below the level of injury.

  • Increased risk for frostbites and pressure ulcers due to reduced skin response and vasomotor control below the lesion level (Theisen71).

  • Careful monitoring of hypothermia.

  • Special attention must be given to wearing appropriate clothing and minimising exposure to cold temperatures.

  • Signs of hypothermia in athletes with SCI should be dealt with at an earlier stage than in the case of able-bodied athletes.

  • Careful monitoring of skin temperature and screening for frostbites and pressure ulcers.

Cerebral palsy
  • Greater metabolic heat at a given workload may be present, heat may potentially be lost more rapidly (Griggs et al76).

  • Botox injections may possibly reduce skin response

  • Potential reduction in already impaired venous return may be attenuated due to even higher muscular tone in response to the cold (higher relative intensity of exercise due to higher heart rate to compensate for lower stroke rate) (Griggs et al76).

  • Cognitive impact on pacing awareness is particularly challenging when competing in cold temperatures (Cameron et al77).

  • Careful monitoring of hypothermia.

  • Special attention must be given to wearing appropriate clothing and minimising exposure to cold temperatures.

Limb deficiency
  • With high-level amputations, skeletal muscle mass may be reduced and heat may be lost more rapidly.

  • Greater metabolic heat production at given workload due to movement asymmetries, heat may potentially be lost more rapidly.

  • Reduced surface area for temperature regulation due to (Griggs et al76)

    • Loss of limb.

    • Residual limb partially covered by prosthesis.

    • Possible skin grafts.

  • Impaired skin response at the athleteprosthetic-interface may potentially lead to increased risk for blisters/sores.

  • Careful monitoring of hypothermia.

  • Special attention must be given to wearing appropriate clothing and minimising exposure to cold temperatures.

Visual impairment
Travel and jetlag (Vanlandewiijck and Thompson78)SCI
  • Potentially increased risk for respiratory tract infections during long flights particularly in athletes with tetraplegia who often have impaired respiratory function.

  • Increased risk for pressure sores during long flights.

  • Increased risk for deep venous thrombosis during long flights.

  • Potentially increased risk for urinary tract infections during long flights.

  • Be extra conscious to minimise the high risk of infection (see table 2).

  • Plan the food and hydration intake during the travel both in relation to timing, hygiene and type of food that is optimal during the travel.

  • During long flights, choose comfortable seating, including customised seat cushions, preferably in business class.

  • Screen for pressure ulcers.

  • Use compression socks designed to avoid deep venous thrombosis.

  • Apply good routines for using bladder catheter on flights.

Cerebral palsy
  • Increased fatigue due to cognitive overload during travelling.

  • Increased spasticity due to stress during travelling.

  • Be particularly aware of the additional load of the travel and its possible impact of the different impairments and make adjustment according to this.

  • Ensure high-quality sleep and enough recovery before departure and after arrival.

  • Reduce training load after arrival.

Limb deficiency
  • Increased risk for ulcers and blisters due to swelling of limbs during long flights.

  • Prostheses should not be worn while travelling.

Visual impairment
  • Disturbance in circadian rhythm is common in athletes with severe visual impairment (Lockley et al79). Adjusting to a new time zone due to not being able to make use of light as a cue may be challenging.

  • General fatigue is common in this athlete population

  • Plan for prolonging the period of adjustment to the new time zone.

  • Prioritise rest.

Athlete health and sports safety
(Vanlandewiijck and Thompson78, Fagher80)
  • Overuse injuries and pain of the shoulder joint(s) are common among athletes using the upper body for mobility in daily life by means of a wheelchair, and during competitions in a XC or Alpine sit-ski.

  • Osteoporosis is common in this population.

  • Pressure ulcers may appear due to new clothes and long competition days.

  • Important to optimise load and recovery.

  • Powered wheelchair to reduce load during daily life in periods with high training or competition load.

  • Screen for fractures and stress fractures following a collision.

  • Monitor for ulcers carefully each day.

Cerebral palsy
  • Spasticity may be aggravated during the games period.

  • Epilepsy may be aggravated during the games period due to stressful situations.

  • Orthopaedic defects may cause pain.

  • Apply physical therapy, medication/injections and braces.

  • Minimise the risk for seizure.

  • Important to optimise load and recovery in order to avoid pain, injury and spasticity.

Limb deficiency
  • Musculoskeletal pain and stress may increase due to compensatory sport movements, and more walking in the Paralympic village.

  • Important to optimise load and recovery in order to ovoid stump and overuse injuries.

Visual impairment
  • Collisions, falls, acute injuries and concussions are common injuries among athletes with visual impairment especially in unfamiliar environments.

  • Ensure optimal guiding and support.

  • We here focus on Paralympic snow-sport athletes with an SCI, cerebral palsy, limb deficiency or visual impairment.