ABC | Volume 113, Nº3, September 2019

Special Article Oliveira Filho et al. Paralympics – addendum to the update on the guidelines for sport and exercise cardiology of the SBC and the SBMEE Arq Bras Cardiol. 2019; 113(3):339-344 Table 2 – Protocols for cardiopulmonary exercise tests for Paralympic athletes (Centro de Estudos em Fisiologia do Exercício – Unifesp/Escola Paulista de Medicina) 8 Wheelchair treadmill CET Initial velocity of 3 to 13 km/h and initial inclination of 0 to 2%, with increments of 0.5 to 1.0 km/h and 0.5 to 1.0% every 3 minutes Treadmill CET Initial velocity of 3 to 8 km/h and initial inclination of 0%, with increments of 0.5 to 1.0 km/h and 0.5 to 5.0% every 3 minutes Exercise bicycle CET Initial load of 25 to 50 watts, with increments of 25 watts every 3 minutes Roller bicycle CET Initial velocity of 30 to 33 km/h, with increments of 3 km/h every 3 minutes Arm ergometer CET Initial load of 25 a 37.5 watts, with increments of 5 to 25 watts every 3 minutes CET: cardiopulmonary exercise test adequate mask sealing. Numerous factors may limit evaluation performance, including: 1) clinical factors: mental and sensorial disabilities (visual, tactile, or hearing impairments, epilepsy, autonomic dysreflexia, neurogenic bladder, sympathetic deprivation, post-polio syndrome, stress-induced tachypnea, malnutrition); 2) locomotive factors: reduced body mass, reduced muscle strength and flexibility, increased muscle tone, reduced joint mobility, reduced motor coordination, osteoarticular injuries secondary to athletic practice, amputation stump injuries; 3) cardiovascular factors: eventual associated infections; 4) physiological factors: reduced peak VO 2 , anaerobic threshold, respiratory compensation point, early fatigue, physical inactivity; 4) socioeconomic and cultural factors: social exclusion, lack of funds. 8 According to the principle of specificity, arm ergometers have been used for tennis players, throwers, weightlifters, fencers, and swimmers; bicycles for cyclists; and treadmills for all other modalities; 8 cyclists may use their own equipment, attached to a Mag 850 Minoura 180 system (class of recommendation: I, level of evidence: C). Athletes should be encouraged to reach their “real” maximum effort. Athletes with cerebral palsy or mental disabilities require prior, detailed explanation regarding the tests, owing to inherent challenges in comprehension. It is possible to carry out the first exams of the day with athletes who have been previously evaluated on other occasions, allowing those who will undergo the test for the first time to watch and understand the execution and objectives of the test. 17 Some precautions should be followed. In athletes with cerebral palsy, there exists a predisposition to accidents (falling), in treadmill tests, due to lack of neuromuscular coordination, especially at higher velocities. In some cases, it is necessary to increment workload using inclination rather than velocity. Due to involuntary facial movements or very acute mandibular angle, the mask or mouthpiece may not seal adequately, and escape may occur in uptake of gases. Athletes with visual impairments, in most cases, will need to maintain contact with their hands on the rail of the treadmill (without leaning on it), and they will need to receive verbal orientation on their biomechanics and spatial situation. Safety belts, which are tied to the athlete’s waist and to the front rail of the treadmill, may be used in some cases. 17 Cardiopulmonary exercise tests may be carried out following numerous specific protocols, examples of which are summarized in Table 2. Knechtle and Köpfli’s 18,19 Protocol (Institute of Sports Medicine, Swiss Paraplegic Centre) for wheelchair treadmill testing begins at a velocity of 8 km/h and an inclination of 1%, with 0.5% increments every 2 minutes and constant velocity, until exhaustion. 18,19 There are also advantages to carrying out field tests. 20 Variations between 48% and 80% have been described in regression equations for determining physical capacity in people with paraplegia and quadriplegia. These variations may be explained by the level and degree of spinal cord injury, age, gender, physical activity, and body weight. In Brazil, values referring to aerobic potential of Paralympic athletes have been similar (Table 3). 21 Pre-participation evaluation for leisure activities is similar, depending on physical and mental stress. In many situations, given the emotional burden involved and the lower level of training, physical and psychological stress may be highly intense, to a degree similar to that of competitions. Preventing injuries/sudden death in sports Injury prevention should include prevention of accidents, aggravation of pre-existing injuries and comorbidities, and sudden death. The objectives of an athletic injury prevention protocol are based on pre-participation screening: 1. Identification of predisposing conditions, or be it, cardiovascular diseases that may potentially cause sudden death; 2. Definition of measures that may be taken to reduce risk of sudden death: “What are they?” “How should they be developed?” 3. Standardization approach to be adopted for each heart disease and discussion of the eventual disqualification of an athlete to exercise his or her profession. Prevention of injuries and sudden deaths in sports and leisure activities is carried out considering early diagnosis and treatment of cardiovascular disorders, as well as the application of up-to-date ineligibility criteria, which are duly applied to Paralympic athletes. 23 It is imperative that competition venues have medical and paramedical resources that are properly equipped for emergency response. In various institutions, the clinical director and/or the attending physician responsible are accountable to the respective Regional Council of Medicine regarding compliance with these norms. Individuals who have been recently hospitalized or who have been sedentary for a long time will require progressive 341