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Practices to Assess External Training Load in Paralympic Sport A Systematic Review Article in Journal of Sport Rehabilitation May 2023 DOI 101123jsr20220110 CITATION 1 READS 257 11 authors including Eduardo Stieler Federal University of Minas Gerais 17 PUBLICATIONS 66 CITATIONS SEE PROFILE Marco Túlio De Mello Federal University of Minas Gerais 470 PUBLICATIONS 13826 CITATIONS SEE PROFILE Ingrid LUDIMILA BASTOS Lôbo Universidade do Estado de Minas Gerais 18 PUBLICATIONS 42 CITATIONS SEE PROFILE Dawit Gonçalves School of Physical Education Physiotherapy and Occupational Therapy EEFFTO F 52 PUBLICATIONS 4714 CITATIONS SEE PROFILE All content following this page was uploaded by Eduardo Stieler on 03 August 2023 The user has requested enhancement of the downloaded file Current Technologies and Practices to Assess External Training Load in Paralympic Sport A Systematic Review Eduardo Stieler123 Marco T de Mello123 Ingrid LB Lôbo14 Dawit A Gonçalves13 Renan Resende13 André G Andrade13 Thiago F Lourenço25 Anselmo AC Silva26 Henrique A Andrade1 Renato Guerreiro13 and Andressa Silva123 1Universidade Federal de Minas Gerais Belo Horizonte MG Brazil 2Academia Paralímpica Brasileira Comitê Paralímpico Brasileiro São Paulo SP Brazil 3Centro de Treinamento Esportivo da Universidade Federal de Minas Gerais Belo Horizonte MG Brazil 4Universidade do Estado de Minas Gerais Ibirité MG Brazil 5Comitê Paralímpico Brasileiro São Paulo SP Brazil 6Universidade Federal do Pará Belém PA Brazil Context Knowing the methods to assess the external load in Paralympic sports can help multidisciplinary teams rely on scientific evidence to better prescribe and monitor the athletes development improving sports performance and reducing the risk of injury illness of Paralympic athletes Objectives This review aimed to systematically explore the current practices of quantifying the external load in Paralympic sports and provide an overview of the methods and techniques used Evidence Acquisition A search in PubMed Web of Science Scopus and EBSCO was carried out until November 2022 The measures of interest were objective methods for quantifying the external load of training or competition The inclusion criteria for the studies were as follows 1 peerreviewed article 2 the population were Paralympic athletes 3 evaluated during training or competition 4 reported at least one external load measure and 5 published in English Portuguese or Spanish Evidence Synthesis Of the 1961 articles found 22 were included because they met the criteria and 8 methods were identified to quantify the external load in training or competition in 8 Paralympic sports The methods varied according to the characteristics of the Paralympic sports To date the devices used included an internal radiofrequencybased tracking system wheelchair rugby a miniaturized data logger wheelchair tennis basketball and rugby a linear position transducer powerlifting and wheelchair basketball a camera swimming goalball and wheelchair rugby a global positioning system wheelchair tennis heart rate monitors that assess external load variables in set paracycling and swimming and an electronic timer swimming Conclusions Different objective methods were identified to assess the external load in Paralympic sports However few studies showed the validity and reliability of these methods Further studies are needed to compare different methods of external load quantification in other Paralympic sports Keywords Paraathlete sports for persons with disabilities athletic performance quantification Key Points Objective measures to quantify the external load in training or competition in Paralympic sports are necessary as they allow the quantification of all the work performed by the athlete in addition to helping the technical team in the organization of training to improve performance and preventrehabilitate injuries Due to the variability of methods used in different modalities this review identified the methods and technologies used to quantify the external load provides significant insights describes how to apply the different methods and proposes practical recommendations for researchers and professionals working in Paralympic sports More studies are needed comparing different methods of external load quantification to advance the validity and reliability of assessments in addition to investigating these methods in other Paralympic modalities with athletes with different types of disabilities The training load in the sports context is described as a fundamental variable to promote and monitor athletes responses1 Load is defined as the sport and nonsportrelated burden single or multiple physiological psychological or mechanical stressors as stimuli applied to a human biological system2 The measures of the training load can be classified as external and internal3 The internal training load is defined as the biological reaction of the athletes organism resulting from the workload performed during exercise4 It refers to psychophysiological responses generated by the exter nal load such as heart rate cortisol concentration and rating perception of effort1 In contrast the external load is characterized by the product of mechanical actions3 as a function of the intensity Stieler httpsorcidorg0000000206376709 de Mello httpsorcidorg0000000338962208 Lôbo httpsorcidorg0000000324355335 Gonçalves httpsorcidorg0000000326213330 Resende httpsorcidorg0000000216093278 AG Andrade httpsorcidorg0000000334064558 Lourenço httpsorcidorg0000000315189021 AAC Silva httpsorcidorg000000015265619X HA Andrade httpsorcidorg0000000271838252 Guerreiro httpsorcidorg0000000164190489 A Silva andressademellonetbr is corresponding author httpsorcidorg 0000000181554723 1 Journal of Sport Rehabilitation Ahead of Print httpsdoiorg101123jsr20220110 2023 Human Kinetics Inc SYSTEMATIC REVIEW First Published Online May 8 2023 and volume of exercises proposed in the planning of the training sessions applied to the athlete35 Examples of external load factors that measure volume include series repetitions and total distance covered whereas measures of intensity include displacement speed angular speed and several highintensity activities15 The primary objective of training for ones sport is to improve physical performance and competitive advantage In this context it is essential to know the effects of frequency duration and intensity of exercise on the magnitude of athletes psychophysiological adaptations For this quantifying and monitoring training loads imposed on athletes are extremely important to drive improvements in physical capacities and specific sports skills46 In this sense depending on the training stimulus external load there may be a positive increase in physical performance or negative injuries pain illness decreased sports performance or overtraining response to the athlete7 However considering that the majority 64 of Paralympic athletes interviewed n 144 by Harrington et al8 reported training 11 hours per week with 34 of athletes reporting missing a competition due to injury and that Fagher et al9 observed a high incidence of injuries with most of these injuries during the training of Paralympic athletes brings the reflection that the application of training loads causes changes in homeostasis affecting psy chological biological and physiological parameters When recovery is inadequate and added to new stimuli external load it can trigger a higher incidence of diseases injuries and pain in athletes1011 In this way monitoring training loads is proposed as one of the strategies to control the organizational parameters of training reducing the risk of musculoskeletal and systemic disorders in athletes712 Although there are different methods for measuring the exter nal training load there is no single measurement or gold standard Thus the choice of methods for quantifying the external training load must consider the sports demands and characteristics13 Therefore coaches and sports scientists seek an increasingly scientific approach to the prescription and monitoring of athletes14 For this the longitudinal track of the individual training load can provide a quantifiable explanation for the changes in sports per formance ensuring that the desired doses quantity and quality of exercise are achieved assisting in the risk of injurydisease man agement15 and optimizing the periodization strategies Concerning sports for athletes without disabilities many studies have shown main results about possibilities for monitor ing external load1617 However in Paralympic sports a system atic review on the subject involved only sports that use a wheelchair18 which despite the relevant contribution to Paralym pic sports disregarded other Paralympic sports that did not need a wheelchair and involved athletes with other disabilities Further more it is noteworthy that the Paralympic Games became the second largest sporting event in the world and the great expan sion of the event was accompanied by an increase in the number of participating athletes an improvement in sports performance an increase in the number of sports and technological advance ments1920 Thus the inherent demands of highperformance sports make the factors influencing the improvement of sports performance of Paralympic athletes with the evaluation monitor ing and adaptation of the training load important for sporting success In this sense although recent advances in external load monitoring technology have provided an increased range of mea sures that can also be used by scientists in the field of Paralympic sports the most appropriate way to measure external load in Paralympic sports as well as in Olympic sports is still little known Thus although there is no gold standard for measuring external load there needs to be some common criteria and variables that researchers and practitioners can agree on so that data on Paralympic athletes can be collected and compared across studies and on a larger scale provide robust evidence for teams involved with different Paralympic sports whether in a wheelchair or not Thus this systematic review aimed to systematically explore the current practices for quantifying external load in Paralympic sports and provide an overview of the methods and techniques used Methods Search Strategy This systematic review was carried out based on the PRISMA guide lines Three independent researchers examined the articles published in the PubMed Web of Science Scopus and EBSCO databases in December 2021 plus a new search to update with the latest articles in November 2022 The keywords were chosen from 3 categories Population Paralymp OR Paraolymp OR Paralymp OR paraolymp OR Parathle OR Paralympic sports OR Paralympic training OR Paralympic games OR Paralympic athletes OR Parathletics Exposure Training OR Match OR Game OR Practice OR Competition Outcomes external load OR external training load OR external TL OR external intensit OR external work OR workload OR physical performance OR physical demand OR match performance OR match demand OR match activit OR match intensit OR game performance OR game demand OR game activit OR gameintensit OR training perfor mance OR training demand OR training activit OR train ing intensit OR training output OR tracking system OR video OR camera OR timemotion OR image recognition system OR match analysis system OR notational analysis OR multicamera system OR global positioning system OR GPS OR micromechanicalelectrical system OR MEMS OR microsensor OR microtechnology OR accelerometry OR inertial measurement unit OR IMU OR distance OR TD OR meters OR lowspeed OR LSR OR LSA OR lowintensit OR LIR OR LIA OR highspeed OR HSR OR HAS OR highintensit OR HIR OR HIA OR maxi malspeed OR maximalintensit OR maximaleffort OR sprint OR repeated sprint OR repeated highintensity effort OR RHIE OR repeated maximaleffort OR repeated maximal bout OR velocity OR speed OR workrest OR worktorest OR accelerat OR decelerat OR impact OR tackl OR collision OR accelerometer load OR body load OR Player Load OR PlayerLoad OR metabolic power OR metabolic load OR high power distance OR equivalent distance OR Pmet OR exertion index Eligibility Criteria There were no restrictions set on the study designs eligible for inclusion The inclusion criteria for the studies were original 2 Stieler et al Ahead of Print research articles the article is related to Paralympic athletes currently in training or competition and has measurements of external load reported at least one measure of external load and full text available in English Spanish or Portuguese In addition the purpose of the included studies was to measure external load or external load was part of a larger objective The exclusion criteria were studies with animals or nonParalympic athletes subjects or without external load measurements reviews surveys opinion pieces books periodicals editorials case studies and nonacademicnonpeerreviewed text Studies were excluded if they did not meet at least one inclusion criterion Study Selection and Data Extraction All articles that appeared in the search were reviewed by 2 indepen dent reviewers and any disagreement was discussed between reviewers First the reviewers removed the articles with duplicate titles and then the titles and abstracts were read Afterward the 2 authors who reviewed the articles read the works in full and verified whether they met the inclusion criteria and whether the journal in which the article was published was peerreviewed Quality Assessment The studies were assessed according to their risk of bias and the specific assessment criteria Table 1 were based on the study by Saw et al21 and adapted by Simim et al19 Scores were allocated based on how well each criterion was met assuming a maximum possible score of 9 low risk of bias Studies with a risk of bias score of 4 were considered poor and their contribution to the results was weighed Results After the search the authors checked the number of articles found in each database searched The same number of articles was found by those responsible in all databases consulted A total of 1961 articles were considered eligible Of these articles 980 were extracted from Scopus 510 from PubMed 245 from Web of Science and 226 from EBSCO After excluding duplicate articles 620 articles 1341 remained After reading the titles 692 articles were excluded After reading the abstracts 390 articles were excluded leaving 259 for a full reading After reading the full texts 241 articles were excluded and 18 were selected for the final review During a new search for articles to include the most recently published works 4 articles were included totaling 22 articles Figure 1 In the 22 articles included in this review external load measures were identified in 8 sports including wheelchair rugby n 9162228 wheelchair basketball n 22930 goalball n 131 powerlifting n 33234 wheelchair tennis n 23536 paracanoeing n 137 paracycling n 138 and swimming n 33942 Table 2 A total of 35 external load variables were divided into speed eg mean propulsive maximum peak and average time eg time to maximum velocity time to perform a task total time in a specific speed zone and relative time spent in speed zone and distance eg total distance relative distance per minute and time and distance in speed zones as main measures of external load Table 2 To evaluate timerelated measures the devices used were a miniaturized data logger wheelchair tennis basketball and rugby an internal radiofrequency RFbased tracking system wheelchair rugby a camera swimming goalball and wheelchair rugby and an electronic timer swimming To evaluate measurements related to speed the devices used were a linear position transducer powerlifting and wheelchair bas ketball a global positioning system GPS SPI Elite TM GPSports System wheelchair tennis a miniaturized data logger wheelchair tennis basketball and rugby a camera swimming goalball and wheelchair rugby a Polar heart rate sensor Polar Electro Oy paracycling and swimming and an internal RFbased tracking system wheelchair rugby To evaluate distancerelated measures the devices used were a miniaturized data logger wheelchair tennis basketball and rugby a GPS wheelchair tennis a camera swimming goalball and wheel chair rugby a Polar heart rate sensor paracycling and swimming and Freelap Cardio Swim heart rate monitors swimming Freelap Timing Systems The summary of these studies is presented in Table 3 The evaluation of the quality of the studies included in this review is shown in Table 4 and there was a good agreement between the 2 reviewers 955 n 21 studies which disagreed only with the study design of Sporner et al29 Discussion The literature demonstrated that in nonParalympic sports there is moderate evidence for a significant relationship between training loads and the incidence of injuries and illnesses7 Thus monitoring the training load is essential for managing the athletes health whatever the sport This systematic review aimed to systematically explore current practices for quantifying external load in Paralym pic sports and provide an overview of the methods and techniques used A total of 22 studies quantified 35 external load variables using 8 methods in 8 Paralympic sports The devices included an Table 1 Criteria for Risk of Bias Assessment Domains Criterion Definition Scoring 0 1 2 D1 Peerreviewed Study published in peerreviewed journal No Yes D2 Number of participants Number of participants included in study findings 5 550 50 D3 Population defined Age gender functional classification sport and experience with time described No Partially Yes D4 Design experimental Design experimental of the study is described and replicable No Partially Yes D5 External load variables training or competition Variables for monitoring training or competition are described No Partially Yes Abbreviation D1D5 domains 15 External Load in Paralympic Sports 3 Ahead of Print internal RFbased tracking system wheelchair rugby a miniatur ized data logger wheelchair tennis basketball and rugby a linear position transducer powerlifting and wheelchair basketball a camera swimming goalball and wheelchair rugby a GPS wheelchair tennis heart rate monitors that assess external load variables in set paracycling and swimming and an electronic timer swimming which provide information on speed eg mean propulsive maximum peak and average time eg time to maximum velocity time to perform a task total time in a specific speed zone and relative time spent in speed zone and distance eg total distance relative distance per minute and time and distance in speed zones Among the external load variables the loadvelocity relation ship has been widely used to predict the 1repetition maximum in lower and upperbody exercises4344 without the need to expose athletes to weighty loads or use protocols until fatigue45 Sports such as wheelchair basketball30 and Paralympic powerlifting that develop strength training programs can benefit from speed assess ment considering that the coach can manipulate speed to optimize performance3234 In Paralympic powerlifting for example where the sports are characterized by strength training3234 devices such as a linear position transducer provide a possibility for manipulating external load variables related to training intensity such as average propul sive speed all paths of the bar where the acceleration of the bar is greater than the acceleration of gravity maximum speed found in the displacement of the bar and torque3234 Although a linear position transducer is the only device used to evaluate external load variables related to velocity in strength training in Paralympic sports so far other devices can be used for accurate measurements of average velocity during exercise bench press on the Smith machine for example and for a lower financial cost46 such as Speed4Lift Velowin PowerLift TForce and Chronojump which have high validity compared to the TrioOptiTrack system that is considered the gold standard47 Paralympic sports such as rugby basketball and wheel chair tennis need to consider other external load variables such as the distance covered at a given speed time during a given speed or heart rate highintensity accelerations and decelera tions and use of spacetime information about the displacement and positioning of the athletes to quantify the external load in these sports22 Among the devices used in the studies included in this systematic review the internal RFbased tracking system was Figure 1 Flowchart showing the selectioninclusion process 4 Stieler et al Ahead of Print the most used162225 and allows quantifying the relative data of external load through the measurement of displacements distances covered average and maximum speed time and distance covered in different speeds and heart rate zones1626 This device is similar to a tag of 25 g with a diameter of 6 cm1626 which can be attached in different places However placing the equipment between the scapula and the athletes vest may present a minor measurement error48 At the same time other lower fixation sites may affect the estimated distance covered although the magnitude of the error between the positions is minimal48 In addition the devices reliability has a coefficient of variation of 05 for the distance traveled and the average speed reached for the peak speed it exceeds 249 To obtain these data the tags communicate wire lessly using a frequency of 8 Hz that emits ultrawideband RF signals that mimic the signals to the sensors elevated around the court where the training is taking place16 A viable alternative for monitoring speed time and distance variables for sports indoors and outdoors in wheelchairs is the miniaturized data logger22 This device is more practical in cali bration and configuration can be done in less time than in the internal RFbased tracking system22 In wheelchair tennis where the distance covered and percent age of total time in specific speed zones during a match or training are essential aspects to consider35 the GPS values for distance and average speed during a game were significantly lower than the values obtained by the miniaturized data logger In addition when using the miniaturized data logger care should be taken with the placement and positioning of the device to increase measurement accuracy In contrast GPS was recommended to use with a sampling frequency of 1 Hz so that it is possible to quantify the information with greater sensitivity36 In the same perspective in wheelchair basketball that requires monitoring of speed change of direction stops and accelerations29 distance and time in speed zones50 it is recommended to use 2 units of the miniaturized data logger to quantify the data that is a miniaturized data logger in each wheel so that it is possible to have more excellent reliability and validity50 In addition to the devices attached to the athlete the processing and analysis of athletes images through videobased computing more specifically videogrammetry51 were also explored in closed environment sports In wheelchair rugby27 with software adapted from football and 2 recording cameras fixed at the highest points of the court the distance covered and the average speed of the athletes were recorded However the number of obstructed views was high 80 and only 20 of athlete tracking was performed automati cally by the system27 In addition there was no comparison to other devices such as the internal RFbased tracking system miniatur ized data recorder or GPS to compare the distance traveled and the average speed captured by this adapted video system which may be a perspective of future studies In contrast image processing and analysis of goalball athletes are an interesting alternative With a video camera positioned at the highest point of the gym52 Monezi et al31 analyzed the number of throws distance covered time speed of the launching phase and average and maximum speed of each athlete Similarly the time and speed of swimming in different pool areas are essential information for coaches and can be measured through videogrammetry3940 For this 3 cameras were fixed on tripods and placed on one side of the pool in the stands with a side view and cones were used to demarcate the areas 75 and 15 m from the beginning and 75 m from the pool wall53 Unlike the previous study Daly et al39 used 5 cameras suspended 16 m above the pool 4 cameras covering onefourth 10 25 m of the pool area 50 m and 8 lanes and one camera covering all routes at the 25m mark The video analysis has an advantage observing the swimmers sports gestures in addition to the time and speed variables However implementation depends on the structure of the place more expensive equipment and trained professionals Table 2 Summary of Methods Used to Measure External Load in Paralympic Sports External load variables Device Sport Speed mean propulsive maximum peak and average Linear position transducer Wheelchair basketball and powerlifters Global positioning system Wheelchair tennis Miniaturized data logger Wheelchair tennis basketball and rugby Camera Wheelchair rugby and swimming Polar heart rate sensor Paracycling Internal radio frequencybased tracking system Wheelchair rugby Time time to maximum velocity time to perform task total time in specific speed zone and relative time spent in speed zone Miniaturized data logger Wheelchair basketball tennis and rugby Internal radiofrequencybased tracking system Wheelchair rugby Camera Swimming and goalball Electronic timing Swimming Distance total and relative distance per minute of time and in speed zones Miniaturized data logger Wheelchair basketball tennis and rugby Global positioning system Wheelchair tennis Camera Wheelchair rugby and goalball Freelap Cardio Swim heart rate monitors Swimming Polar heart rate sensor Paracycling External Load in Paralympic Sports 5 Ahead of Print Table 3 Characteristics of the Included Studies and Their Respective Methods for Evaluating the External Load Study Modality Characteristics of the athletes Period evaluated Equipment Main parameters evaluated Romarate et al30 Wheelchair basketball 10 athletes Disability not reported During training Linear position transducer Mean propulsive velocity Maximum velocity Time to maximum velocity Sinnott OConnor et al41 Swimming 4 athletes Amputee hypochondroplasia les au tres and arthrogryposis During training Freelap Cardio Swim heart rate monitors Distance Neto et al37 Paracanoeing 4 athletes Poliomyelitis peroneal nerve injury and thoracic and lumbar spinal cord injury During training Not declared Distance Teles et al33 Powerlifting 19 athletes Spinal cord injury amputation cere bral palsy and nerve damage in the lower limb During training Linear position transducer Mean propulsive velocity Maximum velocity Resende et al34 Powerlifting 12 athletes Spinal cord injury amputations polio cerebral palsy and arthrogryposis During training Linear position transducer Maximum speed Mason et al28 Wheelchair rugby 31 athletes Spinal cord injury neuromuscular disease cerebral palsy and musculo skeletal dysplasia During competition Internal radiofre quencybased tracking system Relative distance distance traveled per minute of playing time Peak speed highest observed speed Relative time spent in 6 zones of arbitrary speed Loturco et al32 Powerlifting 17 athletes 4 dwarfs and did not report disability of the others During training Linear encoder transducer Torque Bar travel speed Average speed Peak speed Average propulsive speed De Groot et al38 Paracycling 10 athletes Thoracic and lumbar spinal cord injury During training Polar heart rate sensor Mean distance Mean velocity Mean power output Monezi et al31 Goalball 16 athletes Visual impairment During competition Camera Distance traveled during the attack Player speed curve during the launch phase Time spent during the attack PérezTe jero et al40 Swimming 43 athletes Physical disabilities During competition Camera Total time Average speed Griggs et al26 Wheelchair rugby 17 athletes Cervical spinal cord injury cerebral palsy lowerlimb disabilities and lowerlimb amputation During competition Internal radiofre quencybased tracking system Total distance covered m Relative distance Average speed Peak speed Number of highintensity activities Total distance from highintensity activities Rhodes et al24 Wheelchair rugby 8 athletes Disability not reported During training Internal radiofre quencybased tracking system Average speed Maximum speed Relative time spent in 5 zones of arbitrary speed Paulson et al16 Wheelchair rugby 14 athletes Spinal cord injury and other disabilities During training Internal radiofre quencybased tracking system Total distance covered m Time and distance in peak heart rate zones Highintensity activities n Rhodes et al23 Wheelchair rugby 110 men Disability not reported During competition Internal radiofre quencybased tracking system Total distance covered m Relative distance covered mmin in rela tion to the time spent on the court Average and maximum speed ms Time spent in different speed zones Rhodes et al25 Wheelchair rugby 75 athletes Disability not reported During competition Internal radiofre quencybased tracking system Total distance covered m Relative distance mmin Average speed ms Number of highintensity activities Time spent in different zones of arbitrary speed continued 6 Ahead of Print Table 3 continued Study Modality Characteristics of the athletes Period evaluated Equipment Main parameters evaluated Dingley et al42 Swimming 7 athletes 1 man and 6 women Intellectual visually impaired cere bral palsy leg amputee cerebral palsy and small statured During training Electronic timing Total time Sindall et al35 Wheelchair tennis 31 athletes Spinal cord injury amputation and other impairment During competition Miniaturized data logger Distance Percentage of total time within a specific speed zone Mason et al22 Wheelchair rugby 11 athletes Disability not reported During competition Internal radiofre quencybased tracking system Miniaturized data logger Total distance covered m Average speeds Peak speed Time and distance in speed zones Sindall et al36 Wheelchair tennis 15 athletes Disability not reported During competition Global positioning system Miniaturized data logger Distance Average speed Maximum speed Sarro et al27 Wheelchair rugby 8 male athletes Spinal cord injury at cervical level and limb amputated During competition Camera Distance Average speed Sporner et al29 Wheelchair basketball and rugby 38 athletes Cervical thoracic and lumbar spinal cord injury amputation arthritis and multiple sclerosis During competition Miniaturized data logger Total distance covered m Time Speed Stops Daly et al39 Swimming 134 athletes Physical disabilities During competition Camera Total time Four racesegment times Stroke rate Stroke length Table 4 Assessment of Risk of Bias in Included Studies Reference A B C D E Total Romarate et al30 1 2 2 2 2 9 SinnottOConnor et al41 1 2 1 2 2 8 Neto et al37 1 0 2 2 1 6 Teles et al33 1 2 2 2 2 9 Resende et al34 1 2 2 2 2 9 Mason et al28 1 2 1 2 2 8 Loturco et al32 1 1 1 2 2 7 De Groot et al38 1 1 1 2 2 7 Monezi et al31 1 1 1 2 2 7 PérezTejero et al40 1 2 1 2 2 8 Griggs et al26 1 1 1 2 2 7 Rhodes et al24 1 1 1 2 2 7 Paulson et al16 1 2 1 2 2 8 Rhodes et al23 1 2 1 2 2 8 Rhodes et al25 1 1 1 2 2 7 Dingley et al42 1 1 2 2 2 8 Sindall et al35 1 2 2 2 2 9 Mason et al22 1 1 1 2 2 7 Sindall et al36 1 1 1 2 2 7 Sarro et al27 1 1 1 2 2 7 Sporner et al29 1 2 2 2 1 8 Daly et al39 1 2 1 2 2 8 Abbreviations A peerreviewed B number of participants C population defined D design experimental E external load variables training or competition Ahead of Print 7 In this sense heart rate monitors are more practical than cameras for monitoring variables such as distance and average speed in swimming or paracycling considering that video analysis requires a trained professional due to its greater complexity than a device that is easier to configure Thus Freelap Cardio Swim heart rate monitors were used in Paralympic swimming41 to assess the distance covered during training In contrast in paracycling38 a Polar heart rate sensor was used to measure speed and average distance Both studies measured them together with the inter nal load However suppose professionals in the area do not have this equipment and need to evaluate the speed of running in a straight line In that case the automatic timing system evaluates accu rately and reliably54 In Paralympic swimming42 through a 50m timetrial test it is possible to know the average speed and help in the prescription of future exercises in training and the design of new studies Although there is only one study in swimming other Paralympic sports can adapt to their demands and conditions Limitations and Future Perspectives Among the limitations observed in this systematic review was the study with paracanoeing37 which provided information on the distance covered in training but did not report which method to assess the distance used Furthermore in the methodology adopted by this review some sports that were or could become Paralympic sports and that carried out evaluation andor monitoring of the external training load were excluded However it is noteworthy that some studies with football for cerebral palsy used the GPS and from it were able to extract important information from the external load such as total distance distance covered at different intensities maximum speed changes of direction and number of accelerations and decelerations However to scientifically advance the validity and reliability of external load quantification more studies are needed to compare the different methods of external load quantification in other Paralympic sports One example is Paralympic athletics which despite being one of the oldest sports and with the most significant number of athletes and countries participating in the Paralympics there is no study on this sports5556 Conclusions This systematic review provided the first report on assessing external load with objective methods in different Paralympic sports including wheelchair and nonwheelchair sports The meth ods to quantify the external load vary according to the character istics of the Paralympic sports To date the devices used included an internal RFbased tracking system wheelchair rugby a minia turized data logger wheelchair tennis basketball and rugby a linear position transducer powerlifting and wheelchair basketball a camera swimming goalball and wheelchair rugby a GPS wheelchair tennis heart rate monitors that assess external load variables in set paracycling and swimming and an electronic timer swimming However further studies are needed to compare different methods of external load quantification in other Paralym pic sports One of the strengths of this review is that it provided essential information so that coaches sports scientists and multidisciplinary teams can use scientific evidence to better prescribe the external training load and consequently improve sports performance and reduce the risk of injuriesdiseases of athletes in Paralympics sports Acknowledgments The authors thank the support given by ProReitoria de Pesquisa PRPq da Universidade Federal de Minas Gerais Grant 2776427 for Gonçalves CNPq Conselho Nacional de Desenvolvimento Científico e Tecnologico FAPEMIG Fundação de Amparo à Pesquisa do Estado de Minas Gerais CAPES Coordenação de Aperfeiçoamento de Pessoal de Nível Superior Secretaria Especial do Esporte do Ministério da Cidadania Governo Federal Brasília Brazilprotocol numbers 58000008978201837 and N 71000056251202049 Comitê Paralímpico Brasileiro CPB Centro de Treinamento Esportivo of Escola de Educação Física Fisioterapia e Terapia Ocupacional of UFMG CTEEEFFTOUFMG FEPEUFMG Fundação de Apoio ao Ensino Pesquisa e ExtensãoUFMG CEPE Centro de Estudos em Psicobiologia e Exercício and CEMSA Centro Multidisciplinar de Sonolência e Acidentes We are also grateful for the initial collaboration of Professor Dr Maicon Rodrigues Albuquerque and doctoral student Marcio Vidigal Miranda Junior The results of this study do not constitute endorsement of the product by the authors or the National Strength and Conditioning Association This research was conducted without any funding and without conflict of interest Data are not published online however they may be made available if requested to authors The authors of this article declare that the opinions expressed in the submitted article are their own and not an official position of the institution or financier References 1 Bourdon PC Cardinale M Murray A et al Monitoring athlete training loads consensus statement Int J Sports Physiol Perform 201712221612170 doi101123ijspp20170208 2 Soligard T Schwellnus M Alonso JM et al How much is too much Part 1 International Olympic Committee 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