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 3 – Aerobic potential of Brazilian Paralympic athletes participating in the Atlanta Games. Silva AC, Torres FC, Oliveira Filho JA. Avaliação dos atletas paraolímpicos de Atlanta. Unpublished data. Unifesp-EPM, São Paulo, 2006 22 Modality/disability n VO 2max ml.kg – 1 .min -1 Variation ml.kg – 1 .min –1 LA % Football ♂ CP 18 50.6 ± 6.70 36.5 – 62.8 70 ± 9 Swimming ♂ tetra, PM, SCI 7 36.8 ± 17.7 19.8 – 59.0 64 ± 5 Swimming ♀ para, PM, SCI 4 48.9 ± 9.90 35.3 – 61.4 56 ± 9 Basketball ♀ PM, SCI, amp 14 30.0 ± 6.00 20.0 – 40.0 61 ± 8 Tennis ♂ SCI 2 29.7 – 33.3 60 Table tennis ♂ SCI, PM 2 31.0 – 34.5 64.67 Judo ♂ VD 4 45.5 ± 12.0 36.0 – 62.0 59 ± 11 Field/wheel ♂ tetra, PM, CP 3 32.8 ± 10.0 25.0 – 44.0 60 ± 2.9 Field/wheel ♂ para, amp 2 39.0 - 42.0 47.62 Track ♂ VD 3 57.0 ± 7.0 50.0 – 65.0 80 ± 5 Track ♀ VD 2 51.0 – 59.0 46.72 Pentathlon/wheel ♂ para, PM, amp 2 44.0 – 51.0 64.81 amp: amputation; AT: anaerobic threshold; CP: cerebral palsy; para: paraplegia; PM: poliomyelitis; quad: quadriplegia; SCI: spinal cord injury; wheel: wheelchar; VD: visual disability training with gradual increments in exercise intensity and session frequency and duration; in addition to the risks which physical injuries and sequelae present, their appearance may be a factor that discourages training, negatively impacting self-image and predisposing athletes to abandon the program (class of recommendation I, level of evidence C). Ethical Aspects Medical evaluation should include specialists from diverse areas, with exercise and sports medicine, cardiology, orthopedics, and physiatry standing out. When treating athletes with disabilities, it is important to emphasize that it is the physician’s exclusive competence to direct training, diagnose any eventual pathologies and sequelae, request exams, prescribe therapy, and remove athletes from athletic activities; the doctor is not allowed to delegate functions within his or her exclusive competence to individuals who are not qualified to practice medicine (Brazilian Federal Council of Medicine, Resolution nº 1236/87). On the other hand, training should be conducted by physical education instructors and physical therapists. The interaction between doctors, physical education instructors, physical therapists, physiologists, nutritionists, and psychologists is fundamental to a program’s success. Training should be prescribed by means of a medical prescription that states the modality, frequency, and duration of sessions, as well as training intensity and other observations at the attending physician’s discretion. This conduct has been ratified by the Brazilian Federal Council of Medicine Position 4141/2003: “In all of the above, it is the physician’s exclusive competence, following diagnosis of a disease, to prescribe adequate therapy for a patient, including the prescription of physical activity in view of the disease diagnosed or to prevent diverse diseases.” In various institutions, the clinical director and/or responsible attending physician are accountable regarding compliance with these norms before their respective Regional Council of Medicine. Physicians’ relationships with other professionals in the area of healthcare should be based on mutual respect, freedom, and professional independence for all involved, always seeking the interest and well-being of their patients (Brazilian Code of Medical Ethics, January 1, 1988, Article 18). Interaction between physicians, physical education instructors, physical therapists, nutritionists, psychologists, and trainers is fundamental to a training program’s success, and it should be encouraged at all times. Recommendations Currently, given the scarcity of reports in specialized literature, criteria for attending Paralympic athletes are generally based on specialist consensus (level of evidence: C). Determination of athletic eligibility should follow the protocol of the International Paralympic Committee Classification Code and International Standards 24 and the Brazilian Olympic Committee. In this manner, Paralympic athletes may be eligible for one activity and ineligible for another. Athletic eligibility criteria for all Paralympic activities are defined by the respective international federation. Physicians, trainers, and Paralympic athletes should be aware of the risks of eventual and involuntary doping. 25 Since 2000, an overall incidence of < 1% of violations related to doping has been reported in Paralympic competitions. These are generally detected by urine tests during competition periods, comprising a total of 60 violations, 37 of which were in weightlifters. 26 Recommendations for attending Paralympic athletes are listed in Table 4. The practices of doping and boosting are to be severely prohibited. Spinal cord injuries lead to changes in autonomic and cardiovascular function, thus interfering with athletic performance. In these cases of spinal cord injuries at or above level T6, 27 boosting may occur. Boosting intentionally induces autonomic dysreflexia during 342