Adapted Physical Activity Quarterly, 2014, 31, 377-389 http://dx.doi.org/10.1123/apaq.2013-0064 © 2014 Human Kinetics, Inc.
Official Journal of IFAPA www.APAQ-Journal.com RESEARCH
Improvement of the Classification System for Wheelchair Rugby: Athlete Priorities
Viola C. Altmann
Anne L. Hart
Sint Maartenskliniek
Northern Arizona University
Jacques van Limbeek
Yves C. Vanlandewijck
Sint Maartenskliniek
Katholieke Universiteit
A representative sample (N = 302) of the wheelchair rugby population responded to a survey about the classification system based on prioritized items by International Wheelchair Rugby Federation members. Respondents stated, “The classification system is accurate but needs adjustments” (56%), “Any athlete with tetraequivalent impairment should be allowed to compete” (72%), “Athletes with cerebral palsy and other coordination impairments should be classified with a system different than the current one” (75%), and “The maximal value for trunk should be increased from 1.0 to 1.5” (67%). A minority stated, “Wheelchair rugby should only be open to spinal cord injury and other neurological conditions” (36%) and “There should be a 4.0 class” (33%). Results strongly indicated that athletes and stakeholders want adjustments to the classification system in two areas: a focus on evaluation of athletes with impairments other than loss of muscle power caused by spinal cord injury and changes in classification of trunk impairment. Keywords: Paralympics, physical disabilities, wheelchair sport, self-regulation, self-determination
Wheelchair rugby is a team sport developed in Canada in 1977 by athletes with tetraplegia due to spinal-cord injury (SCI) because of a perceived inability to compete in wheelchair basketball (Malone, Morgulec-Adamowics, & Orr, 2011; Orr & Malone, 2010). This history of an “athlete-created” sport is positively acknowledged in the growth of wheelchair rugby and plays a significant role in changes in sport rules and classification (Orr & Malone, 2010; Wu, 2001). Classification is central to Paralympic sports and is defined as a structure for competition to ensure that an athlete’s impairment is relevant to sport performance and to ensure that the athlete competes equitably with other athletes (International Paralympic Committee Altmann is with the Rehabilitation Center, and van Limbeek, the Research Dept., Sint Maartenskliniek, Nijmegen, The Netherlands. Hart is with the Dept. of Physical Therapy and Athlete Training, Northern Arizona University, Flagstaff, AZ. Vanlandewijck is with the Dept. of Rehabilitation Sciences, Katholieke Universiteit, Leuven, Belgium. Address author correspondence to Viola Altmann at v.altmann@ maartenskliniek.nl 377
378 Altmann et al.
[IPC], 2007). The aim of classification is to minimize the impact of impairment on the outcome of the competition, thus ensuring that the success of an athlete is based on parameters of sport, such as power, endurance, tactical ability, and mental focus, rather than on the extent of impairment (Tweedy & Vanlandewijck, 2009). There are seven sport classes in wheelchair rugby, with 0.5-point intervals ranging from 0.5 (most impaired) to 3.5 (least impaired). A 4.0 sport class indicates that the extent of impairment is not sufficient to meet the eligibility criteria for wheelchair rugby at an international competition. For example, athletes with impairments in muscle power consistent with paraplegia are in sport class 4.0. However, national-competition sport rules in some countries permit athletes in the 4.0 sport class to participate in their national competitions. A wheelchair rugby team lineup consists of four athletes with a maximum of 8.0 points on court at any time. Accordingly, sport class has a large impact on team composition and team tactics. The classification system and athlete evaluation process are described in the International Wheelchair Rugby Federation’s (IWRF) classification manual (2011). The wheelchair rugby classification system was originally developed and designed for athletes with impairments in muscle power secondary to complete SCI. The athlete evaluation performed to assign sport class emphasized manual testing of impairment in arm-muscle power (Hislop & Montgomery, 2007), with a maximum point value of 4.0 per arm. Trunk impairment was evaluated with a relatively low maximum point value of 1.0. The average score of both arms and the addition of the trunk score calculate the entry sport class. Until now, the wheelchair rugby classification system has been based on expert opinion and has never been evaluated for validity. According to the available evidence, very little has been reported on the reliability of allocating low-point arm scores based on manual muscle testing (Altmann, Hart, & Parkinson, 2006). Wheelchair rugby became more popular, and athletes with other health conditions such as multiple amputations, cerebral palsy, and neuromuscular disease began to participate in it. These health conditions resulted in impairments other than loss of muscle power, for example, reduced limb length or impairments in coordination. In addition to these new eligible impairments, there were increasing numbers of athletes with incomplete SCI. These athletes retained some degree of muscle power below the lesion level. As a result, classification became more complex. Whereas athletes with complete cervical SCI lack voluntary control of muscles below the level of the lesion, most athletes with incomplete cervical SCI and these other health conditions have voluntary control of trunk and leg muscles. Even though the literature is sparse, there is evidence to suggest an added benefit from muscle power in the trunk and legs for tasks such as reaching and acceleration in wheelchair sprint (Boswell-Ruys, Sturnieks, Harvey, Sherrington, Middleton, & Lord, 2009; Chen, Yeung, Bih, Wang, & Chien, 2003; Dean, Shepherd, & Adams, 1999a, 1999b; Vanlandewijck, Verellen, Beckman, Connick, & Tweedy, 2011; Vanlandewijck, Verellen, & Tweedy, 2011). These tasks are important contributors to sport-specific wheelchair rugby activities and were not considered in the existing classification system. Athletes, coaches, and classifiers noticed differences in sport performance between athletes with and without complete SCI and started to question the validity of the classification system. According to the IPC classification code (2007), international federations should develop evidence-based classification systems through research. An
Athlete Priorities in Classification 379
evidence-based classification system was defined in the IPC position stand (Tweedy & Vanlandewijck, 2009) as a system with the unambiguously stated purpose of promoting participation in sport by minimizing the impact of eligible types of impairment on competition. In addition, empirical evidence must demonstrate how the methods for assigning sport class will achieve this purpose. This study is a first step in developing evidence-based classification using an athlete-centered approach of identifying priority issues in wheelchair rugby classification. This methodology acknowledges the history of the athlete-created sport of wheelchair rugby, as well as Strohkendl’s (1996) principles of athlete self-determination in which athletes assume responsibility for classification. The theoretical foundation that supports soliciting athlete priorities as a first step is grounded in the conceptual basis of involving and empowering patients in health and medical research to enhance the practical relevance and quality of medical knowledge (Abma & Broerse 2010). This methodology for setting the process for health-research agendas is based on the dialogue model described by Abma and Broerse. The dialogue model consists of six phases: exploration, consultation, prioritization, integration, programming, and implementation. The current study, a first step in developing evidence-based classification using the opinion of the athletes and stakeholders to define priorities for improving the classification system, adheres to the first three phases of the dialogue model: the exploration phase, the consultation phase, and the prioritization phase. The possible disadvantage of using an athlete-centered approach particularly considered in this study is that athletes have a personal interest in the game and in the classification system. This interest may cause a bias in their response, which should be taken into consideration in the interpretation of the results. Several priorities in the opinions of the athletes and stakeholders were proposed in the study hypotheses: the classification of athletes with impairment types other than SCI, evaluation of trunk impairment, and defining minimum eligibility for wheelchair rugby. Furthermore, we anticipated the possibility that athletes’ responses might be influenced by the effect a change in the classification system could have on their own sport class. The results of the study will be used to continue the last three phases of the dialogue model: integration of agendas of stakeholders and researchers, development of a research program based on this agenda, and implementation of the research program.
Method Design Statement of Ethics. The IWRF informed participants about this research with
details on how the response to the survey would be anonymous and results would be used to improve wheelchair rugby classification. Furthermore, participants were informed how the results would be disseminated in scholarly presentations and journal articles while safeguarding the identities of individual participants. Participants were guaranteed anonymity in any communication or publication of data from the survey. Participants had to confirm having read and understood this information and agreed to these terms before they could submit the survey. We certify that all applicable institutional and governmental regulations concerning the ethical use
380 Altmann et al.
of human volunteers were followed during the course of this research according to the Helsinki Declaration (“World Medical Association Declaration of Helsinki,” 2008). This was confirmed by the Medical Ethical Committee of the Netherlands, region Arnhem and Nijmegen (registration number 2011/378). Survey Development. In accordance with the exploration phase of the dialogue model (Abma & Broerse, 2010), members of the IWRF classification review committee initiated an open discussion with representatives from 19 out of 26 member nations during the IWRF General Assembly in 2009 at the European Wheelchair Rugby Championships to identify perceived areas of concern in classification. Representatives were athletes, coaches, or team staff who were appointed by their national federation to represent their country. All forwarded topics were listed on a screen visible to all participants. To rank the listed concerns, every representative anonymously prioritized the concerns by attributing 3 points to the concern perceived as most important, 2 points to the second-most important concern, 1 point to the third-most important concern, and no points to the remainder of the list. The ranking of concerns was finalized by summing all individual ratings. It was decided that a topic would be relevant for further exploration if at least 50% of the voting member countries included this topic in their top three choices. Based on these priorities, a survey consisting of six dichotomous questions in English was developed. Additional unstructured responses such as text comments were allowed. This formed the consultation and prioritization phase of the dialogue model. Questions to identify the role of the participant in wheelchair rugby were included. Data Collection. This cross-sectional study aimed to include a wide variety
of athletes and stakeholders from all IWRF member countries. A paper version of the survey was distributed to all 21 teams competing at the three 2009 IWRF zone championships in the Americas, Asia-Oceania, and Europe. In addition, an electronic version was available online from October 2009 to April 2010 using SurveyMonkey (2009). Participants were asked to complete the survey by personal invitation, announcement on the IWRF Web site, and information published through international- and national-federation boards. National classifiers provided translation if needed. Methods were used to limit responses to one survey submission per participant by giving an exact number of labeled copies per team and permitting completion of only one survey per computer. Cross-checking of participant details further reduced the possibility of double entries. The IWRF gave permission to publish the results of the survey.
Participants The survey was completed by 302 individuals. Of these respondents, 219 identified their role in wheelchair rugby as athlete (196), support staff (11), coach (4), or games official (8). There was a slight overrepresentation of athletes in the 0.5-point sport class (See Table 1). In all other sport classes, the response rates approximately matched the proportion of athletes in the corresponding class in the IWRF database (Altmann et al., 2006). Results of the remaining athlete responses were grouped into low-point athletes (sport class 0.5, 1.0, and 1.5), midpoint athletes (sport class
Athlete Priorities in Classification 381
Table 1 Participants’ Deviation According to Wheelchair Rugby Class Respondents, n
% of athlete respondentsa
Athletes in database 9/2010, n
% of athletes in databaseb
0.5 (low-point)
48
24
92
15
1.0 (low-point)
35
18
97
15
1.5 (low-point)
22
11
65
10
2.0 (midpoint)
43
22
148
24
2.5 (midpoint)
14
7
70
11
3.0 (high-point)
26
13
97
15
3.5 (high-point)
6
3
37
6
4.0 (high-point)
2
1
22
4
Not identified as athlete
106
n.a.
n.a.
n.a.
Total
302
Sport class
628
Note. n.a. + not applicable. a Number of athletes who responded in this class/total number of athlete respondents. bNumber of athletes in the database in this class/total number of athletes in the database.
2.0 and 2.5), and high-point athletes (sport classes 3.0, 3.5, and 4.0). There was a representation from 19 of 26 wheelchair rugby countries based on the national identification of 215 respondents. Out of these 215 respondents, 132 (61%) were from a country where English is the native language. However, 39% of the athletes in the IWRF database are native English speakers.
Statistical Procedures Statistical analysis was performed using SPSS (version 17.0, SPSS Inc., Chicago, IL). The population participating in the survey was compared with the 628 athletes with an international wheelchair rugby sport class in the IWRF classification database to assess if the sample of respondents was representative for the wheelchair rugby population. To address possible bias—if the vote of athletes was influenced by the impact a change in the classification system could potentially have on their own sport class—the response of athletes was assessed separately for the low-point (0.5–1.5), midpoint (2.0–2.5), and high-point (3.0–4.0) classes. Because impact on the team lineup, instead of the effect on personal sport class, might also play a role in the vote of individual athletes, analysis was done assessing the answers from athletes from a country whose national team included a dominant high-point athlete with minimum or no trunk impairment separately from athletes from a country whose national teams lacked such a player. Statistical significance of differences between classes or nationalities was calculated using the chi-square test. Whenever a significant difference or a trend was found, Fisher’s exact test was used to analyze the differences between the categories in more detail. The significance level both for the chi-square test and Fisher’s exact test was p < .05.
382 Altmann et al.
Results Survey Development The following topics were screened in the exploration phase: minimum eligibility, athletes with impairment types other than SCI, classification of trunk impairment, consistency of allocated classes, participation of low-point athletes in wheelchair rugby, transparency of classification, range of impairment within a class, and observation of athletes during competition. At least 50% of the voting member countries ranked the following in their top three concerns: minimum eligibility criteria (32 points out of a maximum possible score of 57 points), impact of trunk function on performance (30 points), consistency of sport-class decisions—defined as interrater reliability (16 points), and classification of athletes without SCI (10 points). All other topics were listed in the top three by fewer than 50% of the voting member countries. Interrater reliability is a necessity for any classification system. It has been assessed for athletes with SCI (Altmann et al., 2006), and it should be reassessed as a continuous process to guarantee that an athlete will be allocated the same sport class by any panel of classifiers. This assessment of interrater reliability will need special attention after any changes in the classification system. Therefore, no specific questions to confirm the need for prioritizing interrater reliability were asked in the survey. Questions were directed to the other three topics.
Survey Responses to survey questions are presented in Table 2. For the first question about the current classification system, 56% (95% CI 50–61%) of the participants stated there is no need for the classification system to be completely redone. Instead, they selected the alternative answer: “The classification system is fairly accurate and only requires adjustments (for example, for athletes with limb loss and athletes with cerebral palsy [CP]).” Of all participants, 41% (95% CI 35–47%) chose the option that the classification system needs to be completely redone. There was no significant difference in this opinion between participants who identified as athletes in different sport classes or between participants who did not identify as athletes. In the open statements, respondents gave explanations for their answers concerning a system change with the following open statements: A system for impairments other than SCI should be added (6 respondents who wanted adjustments and 2 respondents who wanted the system completely redone). A change of the system for classification of trunk impairment (4 respondents who wanted adjustments and 2 respondents who wanted the system completely redone). Two respondents stated that they wanted the system to be redone to include a change in the way a tendon transfer to improve elbow extension is classified. Two respondents wanted the system redone to include additional impairment types such as autonomic dysfunction, and 4 respondents wanted the classification system to be redone to be based on observation of activities during the game. Several respondents stated that they wanted new procedures in the application of the classification system rather than a change of the classification system itself as the reason for their answer. Their responses addressed consistency in allocation of sport class (11 respondents) and better procedures against cheating, including more classification evaluations
383
124 (41)
201 (67)
95 (31)
199 (67)
218 (72)
100 (33)
1
2
3
4
5
6
181 (60)
69 (23)
68 (23)
195 (65)
82 (27)
168 (56)
No
19 (6)
15 (5)
21 (7)
12 (11)
19 (6)
10 (3)
NA
47* (45)
83* (79)
65 (62)
31 (30)
79 (75)
46 (44)
Yes
54 (51)
21 (20)
25 (24)
69 (66)
22 (21)
59 (56)
No
4 (4)
1 (1)
7 (7)
4 (4)
4 (4)
0 (0)
NA
Low-Point Athletes
19 (33)
40 (70)
36 (63)
19 (17)
41 (72)
22 (39)
Yes
38 (67)
14 (25)
14 (25)
37 (65)
13 (23)
34 (60)
No
1 (2)
3 (5)
4 (7)
1 (2)
3 (5)
1 (2)
NA
Midpoint Athletes
12 (35)
20* (59)
22 (65)
9 (26)
20 (59)
12 (35)
Yes
21 (62)
13 (38)
6 (18)
23 (68)
13 (38)
21 (62)
No
1 (3)
1 (3)
3 (9)
2 (6)
1 (3)
1 (3)
NA
High-Point Athletes
22* (21)
75 (70)
76 (72)
36 (34)
61 (58)
44 (42)
Yes
68 (64)
21 (20)
23 (22)
66 (62)
34 (32)
54 (51)
No
13 (12)
10 (9)
7 (7)
5 (5)
11 (10)
8 (8)
NA
Not Identified as Athlete
10.00
5.45
0.92
0.78
7.05
1.05
Chisquare
.02
.14
.81
.85
.07
.79
p
Note. NA = no answer. Q 1: Does the current classification system need to be completely redone? Q 2: Should a 1.5 trunk/hip classification be added? Q 3: Should there be a 4.0 class? Q 4: Should athletes with CP and other motor control coordination impairment be classified with a different system than the current one? Q 5: Should wheelchair rugby be open to any athlete with tetraplegia or tetraequivalent impairment? Q 6: should wheelchair rugby only be open to spinal-cord injuries and other neurological conditions? *p < .05 (Fisher’s exact test).
Yes
Q
All Respondents
Table 2 Answers for Each Question (Q) of the Survey, n (%)
384 Altmann et al.
before having a confirmed sport class (4). Of the 11 respondents with comments about inconsistency, 7 suggested adjustments to the current system and 4 wanted the system completely redone. Of the 4 respondents concerned about cheating, 1 wanted adjustments to the current system and 3 wanted the system completely redone. Of all the responses to this question, only 1 stated complete frustration with the classification system: “Classification is an absolute joke.” For the second question, 67% of all participants stated that the maximum score for trunk impairment should be increased from 1.0 to 1.5. The participants who identified as low- and midpoint athletes selected a scoring change for trunk in a larger majority (75% and 72%, respectively) than the participants who identified as high-point athletes (59%) or those who did not identify as athletes (58%); however, this difference was not statistically significant. Answers to this question were compared between respondents on teams with and without an athlete with minimum to no trunk impairment. This description is presented in Table 3. Of the respondents from a country whose national team lacked a dominant athlete with limited to no trunk impairment, 107 (76%) stated “yes” and 33 (24%) stated “no.” Of the respondents of a country with a national team including such an athlete, 31 (60%) stated “yes” and 21 (40%) stated “no.” The differences between these groups were significant. Questions 3–6 explored athlete eligibility and evaluation of athletes with medical conditions other than SCI. In Question 3, 65% preferred not to add an additional 4.0-point class for less-impaired athletes. There was no significant difference between respondents of different categories. Question 4 explored perceptions of respondents on the effectiveness of the current system for athletes with impairments in motor control and coordination; 67% of all respondents stated that a different classification system should be developed to evaluate these athletes. There was no significant difference between respondents of different categories. Question 5 looked at expanding the list of eligible impairments for wheelchair rugby. The majority of respondents stated that “wheelchair rugby should be open to any athlete with tetraequivalent impairment.” Seventy-two percent of all participants chose “yes.” Significantly more low-point athletes than high-point athletes chose “yes” (Fisher’s exact test, p = .037). The respondents who chose “yes” stated the following in the unstructured responses: Inclusion of athletes with conditions other than SCI is needed to let more athletes in the sport (4 respondents), Table 3 Answers to Question 2 per Country Country without athlete with minimum to no trunk impairment on national team
Country with athlete with minimum to no trunk impairment on national team
A 1.5 trunk/hip classification should be added
21
31
A 1.5 trunk/hip classification should not be added
33
107
Answer
Note. Chi-square = 5.3. p = .021.
Athlete Priorities in Classification 385
the classification system should improve for athletes with health conditions other than SCI (12), the maximum point value for trunk needs to increase (3), and the maximum point value of athletes eligible for wheelchair rugby should not exceed 3.5 (6). Four of the respondents who chose “no” added in the unstructured responses that wheelchair rugby was developed for athletes with SCI. No one gave any other reason for voting “no.” Question 6 examined eligible impairments for wheelchair rugby. When asked if wheelchair rugby should only be open to athletes with SCI and other neurological conditions, 60% of all participants selected “no.” Significantly fewer participants who identified as low-point athletes (51%) selected “no” than participants who did not identify as athletes (64%; Fisher’s exact test, p = .002). In the open statements, 5 respondents declared a need to increase the number of athletes participating in the sport, and 17 thought that athletes should not be excluded from the sport based on medical diagnosis. Six also added that the classification system for athletes with medical conditions other than SCI should be improved, and 1 specifically advocated for the addition of a 1.5 value for the trunk. Four “yes” respondents stated that wheelchair rugby was developed for athletes with SCI and should remain that way.
Discussion Athletes and stakeholders in wheelchair rugby identified four priority areas in a review of the classification system and in classification research for this sport. These areas of concern were (a) minimum eligibility criteria, (b) impact of trunk function on performance, (c) reliability of sport-class decisions, and (d) classification of athletes without SCI. The areas of concern (a), (b), and (d) were consistent with those perceived by classifiers as the most problematic and supported the study hypotheses. Specifically, a majority of the athletes and stakeholders supported adjustments to the current classification system rather than a completely new system. However, there was a significant proportion of the respondents who stated that the classification system needed to be completely redone. Taking into account the confidence intervals of the sample, this minority almost equaled the majority. Therefore, we felt it was insufficient to only take the majority vote into account and we explored the reason for the vote per respondent using the open statements. This exploration showed that the reason for the vote often showed overlap between the group that wanted a completely new system and the group that wanted adjustments. Several respondents expressed concerns about the application of classification. A change or adjustment in the classification system cannot resolve these concerns. For example, an inadequate classification system can be as reliably administered as a valid and evidence-based system. More important, these issues should be addressed in evaluation of classification procedures and in educating and training classifiers and athletes. Out of a total of 302 survey respondents, only 1 formulated a statement in the open response that suggested a deep discontent with classification. Based on the open responses, we were convinced that adjusting the system instead of developing a whole new system was the best choice and did not neglect the opinion of the minority. The recommended adjustments were evaluation of the trunk, with an increased maximum value, and revisions for athletes with impairments other than muscle
386 Altmann et al.
power, the typical impairment in athletes with SCI. The majority of participants stated that athletes should be eligible for wheelchair rugby, regardless of the medical condition causing impairment. However, respondents were not supportive of the idea that athletes with a total point value higher than 3.5 should participate in this sport. Research on the perception of athletes and stakeholders relating to classification in Paralympic sports is rare. Strohkendl (1978, 1996) did extensive work designing a new classification system for wheelchair basketball based on the concept of athlete self-determination. Strohkendl (1996) defined self-determination of athletes: “The players learn to assume responsibility for the system by proposing their own classification, controlling the classification of others, or even by functioning as classifiers” (p. 53). Strohkendl questioned whether “the methods of natural science are appropriate to assess such a complex issue as the physical potential of wheelchair basketball players.” In addition, he claimed that “players know what is limiting and what is helpful when playing wheelchair basketball. Possessing a profound knowledge to sense the physical potential of a typical player of a class, they also succeed in classifying players with disabilities other than paraplegia” (p. 53). Based on these assumptions, Strohkendl created an experience-based wheelchair basketball classification system based on dialogue with athletes in wheelchair basketball who were dissatisfied with the medical classification system used for all sports at that time. However, he provided no details about the athlete group involved or description of the method used for the dialogue. As a result of this absence of descriptions of the sample and methodology, bias may have occurred in a possible nonrepresentative sample of athletes and in an unknown method of recording the athlete responses. Some aspects of this wheelchair basketball classification system seem to be contradictory with the principles of self-determination. According to Strohkendl, classification takes place through fair dialogue and should be as simple as possible. However, implicit knowledge learned by experience is not easy to appreciate by less-experienced athletes and stakeholders and is not open for discussion on an equal level with classifiers. Thus, the provisions of fair dialogue and a simple system may not be present. We found no other published research exploring athletes’ perception of classification. Based on the extensive responses in this study, the opportunity for athletes and sport stakeholders to be involved in developing the classification system seems to be highly valued. Those in wheelchair rugby also concur that athlete involvement is important in the development of evidencebased classification systems. Based on the IWRF’s classification manual (2011), there is no consensus that athletes should propose their own sport class and control the classification of others (p. 55). The potential disadvantage of adopting a fully athlete-centered approach is that athletes have an interest in the game, and thus in classification, which affects the game. If this situation would indeed cause bias, then answers to several questions on the survey, especially Questions 2, 5, and 6, were expected to differ per athlete sport class. Therefore, all answers were analyzed both for the total group of respondents and per athlete sport class. We had expected athlete respondents in the low-point classes to disagree with those in the high-point classes about increasing the maximum score for trunk impairment. This assumption was based on the greater likelihood of impact of the revised trunk-impairment evaluation on athletes in high-point classes, who would more likely see their sport class change or possibly become ineligible (IWRF, 2011). This hypothesis was not confirmed. However, if a national team had one or more
Athlete Priorities in Classification 387
high-point athletes with limited to no trunk impairment, the entire team seemed less supportive of this change in the system. Indeed, if the maximum value for trunk function increased, team lineups would be affected and these athletes might be allowed less time on the court or not play at all. Finding no difference between athletes categorized by sport class can be explained by the representation across all sport classes in the composition of a team. Based on these findings, we concluded that personal interest in the game and consequently in classification plays a role in the athlete responses; however, the interest in the team lineup seemed to play a larger role than personal interest in sport class. We also had expected a difference between categories of respondents based on personal sport class regarding the inclusion of athletes with medical conditions other than SCI. There was a difference in the number of athletes with particular health conditions in the low-point classes (3% with non-SCI) and high-point classes (22% with non-SCI; Altmann et al., 2006), so we expected those in the high-point class to choose “yes.” In contrast to the expectations, athletes in the high-point classes chose “yes” less frequently than the athletes in the low-point classes. This may also be explained by a greater interest in the team lineup than interest in the personal class of the responding athletes. Athletes in the high-point class experience direct competition for lineup positions by those athletes without SCI in the same class, who are perceived to be less impaired. Thus, it would seem to be against the interest of high-point SCI athletes to allow non-SCI athletes to participate. However, the number of athletes in the high-point classes is relatively small; consequently, the number of respondents was low. Possibly, a relatively large proportion of high-point athletes who responded were those with SCI, which would clarify this effect in the response. It is interesting that low-point athletes have a better chance of being on court with an increase in number of high-point athletes, because with the maximum of 8.0 points on court, in any lineup a low-point athlete must be combined with a high-point athlete. Therefore, increasing the number of high-point athletes, regardless of medical condition, is in the interest of low-point athletes. This study demonstrates that the opinion of athletes and stakeholders in Paralympic sport is a valuable tool for evaluating and improving classification systems. Nevertheless, personal interest may play a role in survey responses. This personal interest of (active) athletes and coaches in classification should always be taken into consideration when involving these groups in classification decisions as advocated by Strohkendl (1978, 1996). By systematic assessment of the opinion of athletes and stakeholders, valuable expert information can be made explicit and corrected for bias if necessary. With this method, athlete self-determination is respected, including transparency in classification and providing an opportunity to continue an open and fair dialogue about classification. A representative number of respondents and representation of respondents in each of the seven sport classes controlled for other biases. The group responding to the survey (302) reflected a large sample compared with the population of athletes with an international sport class (628). In addition, the sample was representative based on the distribution of sport classes. Even so, several biases in this research may have occurred. First, a large number of participants did not indicate their role in the sport. Therefore, we analyzed results of the athletes separately from the answers of all other respondents who did not identify their role. There are several possible explanations for why respondents did not identify. Perhaps the nonathletes thought their anonymity would be lost by
388 Altmann et al.
revealing nationality and role in a team and so refrained from sharing these details. However, the ability to determine if a respondent was an athlete was not possible without these details. Language was another possible source of bias because of the overrepresentation of native English speakers. Because questions were in English and translation was only offered on request, nonnative speakers may have been discouraged from responding, consequently creating an overrepresentation of native English speakers in the response. Using survey questions with simple dichotomous answers and including optional open statements was an attempt to control the effect of language on the response rate. Because of the dichotomous questions and the limited number of added open statements, important aspects of the opinions of the respondents may have been missed. This study is possibly the first time a systematic assessment of this type and scope has been done involving athletes and stakeholders in revision or development of a classification system in Paralympic sport. Although classification is moving toward an evidence-based foundation, this extensive goal can only be accomplished one step at a time. This research completed the first three phases of the dialogue model (Abma & Broerse 2010). The results were presented to the general assembly of the IWRF in 2010, thus completing the integration phase, the fourth phase of the dialogue model. A discussion was conducted with representatives of all IWRF member countries to determine the agenda for adjustments in the classification system and to set the start of a research program to achieve this agenda. The next steps will include the programming phase and the implementation phase, which will consist of adjustments in the evaluation of the trunk (with an increased maximum value) and revisions for athletes with impairments other than muscle power (the typical impairment for athletes with SCI). The first step in the implementation phase is in process and examines the extent of trunk impairment and the impact on sport-specific activities in wheelchair rugby, including both a systematic literature review and conducting experimental studies. In the experimental studies, athletes with medical conditions other than SCI, as well as those with incomplete SCI, will be included. The ultimate goal is to develop an evidence-based classification system for all eligible impairments in wheelchair rugby that determines the impact of eligible impairments on sport-specific activities in wheelchair rugby. The aim is to develop a system that is transparent, reliable, and accepted by athletes and others involved in wheelchair rugby. Acknowledgment This research was supported by the International Wheelchair Rugby Federation (IWRF) by facilitating the access to the survey to all athletes and stakeholders in wheelchair rugby
References Abma, T.A., & Broerse, J.E. (2010). Patient participation as dialogue: Setting research agendas. Health expectations, 13(2), 160–173. PubMed doi:10.1111/j.13697625.2009.00549.x Altmann, V.C., Hart, A., & Parkinson, A. (2006). Wheelchair rugby classification database: Aid to the improvement of classification. Fourth IPC Vista conference, Classification: Solutions for the future. Conference Proceedings. IPC. CD-ROM.
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Boswell-Ruys, C.L., Sturnieks, D.L., Harvey, L.A., Sherrington, C., Middleton, J.W., & Lord, S.R. (2009). Validity and reliability of assessment tools for measuring unsupported sitting in people with a spinal cord injury. Archives of Physical Medicine and Rehabilitation, 90, 1571–1577. PubMed doi:10.1016/j.apmr.2009.02.016 Chen, C.L., Yeung, K.T., Bih, L.I., Wang, C.H., & Chien, J.C. (2003). The relationship between sitting stability and functional performance in patients with paraplegia. Archives of Physical Medicine and Rehabilitation, 84, 1276–1281. PubMed doi:10.1016/S00039993(03)00200-4 Dean, C., Shepherd, R., & Adams, R. (1999a). Sitting balance I: Trunk–arm coordination and the contribution of the lower limbs during self-paced reaching in sitting. Gait & Posture, 10, 135–146. PubMed doi:10.1016/S0966-6362(99)00026-0 Dean, C.M., Shepherd, R., & Adams, R. (1999b). Sitting balance II: Reach direction and thigh support affect the contribution of the lower limbs when reaching beyond arm’s length in sitting. Gait & Posture, 10, 147–153. PubMed doi:10.1016/S0966-6362(99)00027-2 Hislop, H.J., & Montgomery, J. (2007). Daniels and Worthingham’s muscle testing: Techniques of manual examination (8th ed.). Philadelphia, PA: W.B. Saunders. International Paralympic Committee. (2007). IPC classification code and international standards. Retrieved from http://www.paralympic.org/Classification/Code International Wheelchair Rugby Federation. (2011). International wheelchair rugby classification manual (3rd ed. rev.). Retrieved from http://www.iwrf.com/?page=classification Malone, L.A., Morgulec-Adamowics, N., & Orr, K. (2011). Contribution of sport science to performance—Wheelchair rugby. In Y.C. Vanlandewijck & W. Thompson (Eds.), The Paralympic athlete (pp. 249–263). Chichester, UK: Wiley-Blackwell. Orr, K., & Malone, L.A. (2010). Wheelchair rugby. In V. Goosey-Tolfrey (Ed.), Wheelchair sport. A complete guide for athletes, coaches and teachers (pp. 151–166). Champaign, IL: Human Kinetics. Strohkendl, H. (1996). Player classification. In A. Thiboutot (Ed.), The 50th anniversary of wheelchair basketball. A History by Horst Strohkendl (pp. 47–53). Münster, Germany, and New York: Waxmann. Strohkendl, H. (1978). Funktionelle Klassifizierung für den Rollstuhlsport [Functional classification in wheelchair sport]. Berlin, Germany: Springer-Verlag Survey Monkey (2009). Retrieved from http://www.surveymonkey.com Tweedy, S.M., & Vanlandewijck, Y.C. (2009). International Paralympic Committee position stand—Background and scientific rationale for classification in Paralympic sport. British Journal of Sports Medicine. In press. Doi:10.1136/bjsm.2009.065060 Vanlandewijck, Y.C., Verellen, J., Beckman, E., Connick, M., & Tweedy, S.M. (2011). Trunk strength effect on track wheelchair start: Implications for classification. Medicine and Science in Sports and Exercise, 43(12), 2344–2351. PubMed doi:10.1249/ MSS.0b013e318223af14 Vanlandewijck, Y.C., Verellen, J., & Tweedy, S. (2011). Towards evidence-based classification in wheelchair sports: Impact of seating position on wheelchair acceleration. Journal of Sports Sciences, 29(10), 1089–1096. PubMed doi:10.1080/02640414.2011.576694 World Medical Association declaration of Helsinki. (October 2008). Retrieved from http:// www.wma.net/en/30publications/10policies/b3/17c.pdf Wu, S.K. (2001). Classifiers and social control in wheelchair rugby. Kaohsiung Journal of Medical Sciences, 17(2), 90–98. PubMed
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Official Journal of IFAPA www.APAQ-Journal.com RESEARCH
Improvement of the Classification System for Wheelchair Rugby: Athlete Priorities
Viola C. Altmann
Anne L. Hart
Sint Maartenskliniek
Northern Arizona University
Jacques van Limbeek
Yves C. Vanlandewijck
Sint Maartenskliniek
Katholieke Universiteit
A representative sample (N = 302) of the wheelchair rugby population responded to a survey about the classification system based on prioritized items by International Wheelchair Rugby Federation members. Respondents stated, “The classification system is accurate but needs adjustments” (56%), “Any athlete with tetraequivalent impairment should be allowed to compete” (72%), “Athletes with cerebral palsy and other coordination impairments should be classified with a system different than the current one” (75%), and “The maximal value for trunk should be increased from 1.0 to 1.5” (67%). A minority stated, “Wheelchair rugby should only be open to spinal cord injury and other neurological conditions” (36%) and “There should be a 4.0 class” (33%). Results strongly indicated that athletes and stakeholders want adjustments to the classification system in two areas: a focus on evaluation of athletes with impairments other than loss of muscle power caused by spinal cord injury and changes in classification of trunk impairment. Keywords: Paralympics, physical disabilities, wheelchair sport, self-regulation, self-determination
Wheelchair rugby is a team sport developed in Canada in 1977 by athletes with tetraplegia due to spinal-cord injury (SCI) because of a perceived inability to compete in wheelchair basketball (Malone, Morgulec-Adamowics, & Orr, 2011; Orr & Malone, 2010). This history of an “athlete-created” sport is positively acknowledged in the growth of wheelchair rugby and plays a significant role in changes in sport rules and classification (Orr & Malone, 2010; Wu, 2001). Classification is central to Paralympic sports and is defined as a structure for competition to ensure that an athlete’s impairment is relevant to sport performance and to ensure that the athlete competes equitably with other athletes (International Paralympic Committee Altmann is with the Rehabilitation Center, and van Limbeek, the Research Dept., Sint Maartenskliniek, Nijmegen, The Netherlands. Hart is with the Dept. of Physical Therapy and Athlete Training, Northern Arizona University, Flagstaff, AZ. Vanlandewijck is with the Dept. of Rehabilitation Sciences, Katholieke Universiteit, Leuven, Belgium. Address author correspondence to Viola Altmann at v.altmann@ maartenskliniek.nl 377
378 Altmann et al.
[IPC], 2007). The aim of classification is to minimize the impact of impairment on the outcome of the competition, thus ensuring that the success of an athlete is based on parameters of sport, such as power, endurance, tactical ability, and mental focus, rather than on the extent of impairment (Tweedy & Vanlandewijck, 2009). There are seven sport classes in wheelchair rugby, with 0.5-point intervals ranging from 0.5 (most impaired) to 3.5 (least impaired). A 4.0 sport class indicates that the extent of impairment is not sufficient to meet the eligibility criteria for wheelchair rugby at an international competition. For example, athletes with impairments in muscle power consistent with paraplegia are in sport class 4.0. However, national-competition sport rules in some countries permit athletes in the 4.0 sport class to participate in their national competitions. A wheelchair rugby team lineup consists of four athletes with a maximum of 8.0 points on court at any time. Accordingly, sport class has a large impact on team composition and team tactics. The classification system and athlete evaluation process are described in the International Wheelchair Rugby Federation’s (IWRF) classification manual (2011). The wheelchair rugby classification system was originally developed and designed for athletes with impairments in muscle power secondary to complete SCI. The athlete evaluation performed to assign sport class emphasized manual testing of impairment in arm-muscle power (Hislop & Montgomery, 2007), with a maximum point value of 4.0 per arm. Trunk impairment was evaluated with a relatively low maximum point value of 1.0. The average score of both arms and the addition of the trunk score calculate the entry sport class. Until now, the wheelchair rugby classification system has been based on expert opinion and has never been evaluated for validity. According to the available evidence, very little has been reported on the reliability of allocating low-point arm scores based on manual muscle testing (Altmann, Hart, & Parkinson, 2006). Wheelchair rugby became more popular, and athletes with other health conditions such as multiple amputations, cerebral palsy, and neuromuscular disease began to participate in it. These health conditions resulted in impairments other than loss of muscle power, for example, reduced limb length or impairments in coordination. In addition to these new eligible impairments, there were increasing numbers of athletes with incomplete SCI. These athletes retained some degree of muscle power below the lesion level. As a result, classification became more complex. Whereas athletes with complete cervical SCI lack voluntary control of muscles below the level of the lesion, most athletes with incomplete cervical SCI and these other health conditions have voluntary control of trunk and leg muscles. Even though the literature is sparse, there is evidence to suggest an added benefit from muscle power in the trunk and legs for tasks such as reaching and acceleration in wheelchair sprint (Boswell-Ruys, Sturnieks, Harvey, Sherrington, Middleton, & Lord, 2009; Chen, Yeung, Bih, Wang, & Chien, 2003; Dean, Shepherd, & Adams, 1999a, 1999b; Vanlandewijck, Verellen, Beckman, Connick, & Tweedy, 2011; Vanlandewijck, Verellen, & Tweedy, 2011). These tasks are important contributors to sport-specific wheelchair rugby activities and were not considered in the existing classification system. Athletes, coaches, and classifiers noticed differences in sport performance between athletes with and without complete SCI and started to question the validity of the classification system. According to the IPC classification code (2007), international federations should develop evidence-based classification systems through research. An
Athlete Priorities in Classification 379
evidence-based classification system was defined in the IPC position stand (Tweedy & Vanlandewijck, 2009) as a system with the unambiguously stated purpose of promoting participation in sport by minimizing the impact of eligible types of impairment on competition. In addition, empirical evidence must demonstrate how the methods for assigning sport class will achieve this purpose. This study is a first step in developing evidence-based classification using an athlete-centered approach of identifying priority issues in wheelchair rugby classification. This methodology acknowledges the history of the athlete-created sport of wheelchair rugby, as well as Strohkendl’s (1996) principles of athlete self-determination in which athletes assume responsibility for classification. The theoretical foundation that supports soliciting athlete priorities as a first step is grounded in the conceptual basis of involving and empowering patients in health and medical research to enhance the practical relevance and quality of medical knowledge (Abma & Broerse 2010). This methodology for setting the process for health-research agendas is based on the dialogue model described by Abma and Broerse. The dialogue model consists of six phases: exploration, consultation, prioritization, integration, programming, and implementation. The current study, a first step in developing evidence-based classification using the opinion of the athletes and stakeholders to define priorities for improving the classification system, adheres to the first three phases of the dialogue model: the exploration phase, the consultation phase, and the prioritization phase. The possible disadvantage of using an athlete-centered approach particularly considered in this study is that athletes have a personal interest in the game and in the classification system. This interest may cause a bias in their response, which should be taken into consideration in the interpretation of the results. Several priorities in the opinions of the athletes and stakeholders were proposed in the study hypotheses: the classification of athletes with impairment types other than SCI, evaluation of trunk impairment, and defining minimum eligibility for wheelchair rugby. Furthermore, we anticipated the possibility that athletes’ responses might be influenced by the effect a change in the classification system could have on their own sport class. The results of the study will be used to continue the last three phases of the dialogue model: integration of agendas of stakeholders and researchers, development of a research program based on this agenda, and implementation of the research program.
Method Design Statement of Ethics. The IWRF informed participants about this research with
details on how the response to the survey would be anonymous and results would be used to improve wheelchair rugby classification. Furthermore, participants were informed how the results would be disseminated in scholarly presentations and journal articles while safeguarding the identities of individual participants. Participants were guaranteed anonymity in any communication or publication of data from the survey. Participants had to confirm having read and understood this information and agreed to these terms before they could submit the survey. We certify that all applicable institutional and governmental regulations concerning the ethical use
380 Altmann et al.
of human volunteers were followed during the course of this research according to the Helsinki Declaration (“World Medical Association Declaration of Helsinki,” 2008). This was confirmed by the Medical Ethical Committee of the Netherlands, region Arnhem and Nijmegen (registration number 2011/378). Survey Development. In accordance with the exploration phase of the dialogue model (Abma & Broerse, 2010), members of the IWRF classification review committee initiated an open discussion with representatives from 19 out of 26 member nations during the IWRF General Assembly in 2009 at the European Wheelchair Rugby Championships to identify perceived areas of concern in classification. Representatives were athletes, coaches, or team staff who were appointed by their national federation to represent their country. All forwarded topics were listed on a screen visible to all participants. To rank the listed concerns, every representative anonymously prioritized the concerns by attributing 3 points to the concern perceived as most important, 2 points to the second-most important concern, 1 point to the third-most important concern, and no points to the remainder of the list. The ranking of concerns was finalized by summing all individual ratings. It was decided that a topic would be relevant for further exploration if at least 50% of the voting member countries included this topic in their top three choices. Based on these priorities, a survey consisting of six dichotomous questions in English was developed. Additional unstructured responses such as text comments were allowed. This formed the consultation and prioritization phase of the dialogue model. Questions to identify the role of the participant in wheelchair rugby were included. Data Collection. This cross-sectional study aimed to include a wide variety
of athletes and stakeholders from all IWRF member countries. A paper version of the survey was distributed to all 21 teams competing at the three 2009 IWRF zone championships in the Americas, Asia-Oceania, and Europe. In addition, an electronic version was available online from October 2009 to April 2010 using SurveyMonkey (2009). Participants were asked to complete the survey by personal invitation, announcement on the IWRF Web site, and information published through international- and national-federation boards. National classifiers provided translation if needed. Methods were used to limit responses to one survey submission per participant by giving an exact number of labeled copies per team and permitting completion of only one survey per computer. Cross-checking of participant details further reduced the possibility of double entries. The IWRF gave permission to publish the results of the survey.
Participants The survey was completed by 302 individuals. Of these respondents, 219 identified their role in wheelchair rugby as athlete (196), support staff (11), coach (4), or games official (8). There was a slight overrepresentation of athletes in the 0.5-point sport class (See Table 1). In all other sport classes, the response rates approximately matched the proportion of athletes in the corresponding class in the IWRF database (Altmann et al., 2006). Results of the remaining athlete responses were grouped into low-point athletes (sport class 0.5, 1.0, and 1.5), midpoint athletes (sport class
Athlete Priorities in Classification 381
Table 1 Participants’ Deviation According to Wheelchair Rugby Class Respondents, n
% of athlete respondentsa
Athletes in database 9/2010, n
% of athletes in databaseb
0.5 (low-point)
48
24
92
15
1.0 (low-point)
35
18
97
15
1.5 (low-point)
22
11
65
10
2.0 (midpoint)
43
22
148
24
2.5 (midpoint)
14
7
70
11
3.0 (high-point)
26
13
97
15
3.5 (high-point)
6
3
37
6
4.0 (high-point)
2
1
22
4
Not identified as athlete
106
n.a.
n.a.
n.a.
Total
302
Sport class
628
Note. n.a. + not applicable. a Number of athletes who responded in this class/total number of athlete respondents. bNumber of athletes in the database in this class/total number of athletes in the database.
2.0 and 2.5), and high-point athletes (sport classes 3.0, 3.5, and 4.0). There was a representation from 19 of 26 wheelchair rugby countries based on the national identification of 215 respondents. Out of these 215 respondents, 132 (61%) were from a country where English is the native language. However, 39% of the athletes in the IWRF database are native English speakers.
Statistical Procedures Statistical analysis was performed using SPSS (version 17.0, SPSS Inc., Chicago, IL). The population participating in the survey was compared with the 628 athletes with an international wheelchair rugby sport class in the IWRF classification database to assess if the sample of respondents was representative for the wheelchair rugby population. To address possible bias—if the vote of athletes was influenced by the impact a change in the classification system could potentially have on their own sport class—the response of athletes was assessed separately for the low-point (0.5–1.5), midpoint (2.0–2.5), and high-point (3.0–4.0) classes. Because impact on the team lineup, instead of the effect on personal sport class, might also play a role in the vote of individual athletes, analysis was done assessing the answers from athletes from a country whose national team included a dominant high-point athlete with minimum or no trunk impairment separately from athletes from a country whose national teams lacked such a player. Statistical significance of differences between classes or nationalities was calculated using the chi-square test. Whenever a significant difference or a trend was found, Fisher’s exact test was used to analyze the differences between the categories in more detail. The significance level both for the chi-square test and Fisher’s exact test was p < .05.
382 Altmann et al.
Results Survey Development The following topics were screened in the exploration phase: minimum eligibility, athletes with impairment types other than SCI, classification of trunk impairment, consistency of allocated classes, participation of low-point athletes in wheelchair rugby, transparency of classification, range of impairment within a class, and observation of athletes during competition. At least 50% of the voting member countries ranked the following in their top three concerns: minimum eligibility criteria (32 points out of a maximum possible score of 57 points), impact of trunk function on performance (30 points), consistency of sport-class decisions—defined as interrater reliability (16 points), and classification of athletes without SCI (10 points). All other topics were listed in the top three by fewer than 50% of the voting member countries. Interrater reliability is a necessity for any classification system. It has been assessed for athletes with SCI (Altmann et al., 2006), and it should be reassessed as a continuous process to guarantee that an athlete will be allocated the same sport class by any panel of classifiers. This assessment of interrater reliability will need special attention after any changes in the classification system. Therefore, no specific questions to confirm the need for prioritizing interrater reliability were asked in the survey. Questions were directed to the other three topics.
Survey Responses to survey questions are presented in Table 2. For the first question about the current classification system, 56% (95% CI 50–61%) of the participants stated there is no need for the classification system to be completely redone. Instead, they selected the alternative answer: “The classification system is fairly accurate and only requires adjustments (for example, for athletes with limb loss and athletes with cerebral palsy [CP]).” Of all participants, 41% (95% CI 35–47%) chose the option that the classification system needs to be completely redone. There was no significant difference in this opinion between participants who identified as athletes in different sport classes or between participants who did not identify as athletes. In the open statements, respondents gave explanations for their answers concerning a system change with the following open statements: A system for impairments other than SCI should be added (6 respondents who wanted adjustments and 2 respondents who wanted the system completely redone). A change of the system for classification of trunk impairment (4 respondents who wanted adjustments and 2 respondents who wanted the system completely redone). Two respondents stated that they wanted the system to be redone to include a change in the way a tendon transfer to improve elbow extension is classified. Two respondents wanted the system redone to include additional impairment types such as autonomic dysfunction, and 4 respondents wanted the classification system to be redone to be based on observation of activities during the game. Several respondents stated that they wanted new procedures in the application of the classification system rather than a change of the classification system itself as the reason for their answer. Their responses addressed consistency in allocation of sport class (11 respondents) and better procedures against cheating, including more classification evaluations
383
124 (41)
201 (67)
95 (31)
199 (67)
218 (72)
100 (33)
1
2
3
4
5
6
181 (60)
69 (23)
68 (23)
195 (65)
82 (27)
168 (56)
No
19 (6)
15 (5)
21 (7)
12 (11)
19 (6)
10 (3)
NA
47* (45)
83* (79)
65 (62)
31 (30)
79 (75)
46 (44)
Yes
54 (51)
21 (20)
25 (24)
69 (66)
22 (21)
59 (56)
No
4 (4)
1 (1)
7 (7)
4 (4)
4 (4)
0 (0)
NA
Low-Point Athletes
19 (33)
40 (70)
36 (63)
19 (17)
41 (72)
22 (39)
Yes
38 (67)
14 (25)
14 (25)
37 (65)
13 (23)
34 (60)
No
1 (2)
3 (5)
4 (7)
1 (2)
3 (5)
1 (2)
NA
Midpoint Athletes
12 (35)
20* (59)
22 (65)
9 (26)
20 (59)
12 (35)
Yes
21 (62)
13 (38)
6 (18)
23 (68)
13 (38)
21 (62)
No
1 (3)
1 (3)
3 (9)
2 (6)
1 (3)
1 (3)
NA
High-Point Athletes
22* (21)
75 (70)
76 (72)
36 (34)
61 (58)
44 (42)
Yes
68 (64)
21 (20)
23 (22)
66 (62)
34 (32)
54 (51)
No
13 (12)
10 (9)
7 (7)
5 (5)
11 (10)
8 (8)
NA
Not Identified as Athlete
10.00
5.45
0.92
0.78
7.05
1.05
Chisquare
.02
.14
.81
.85
.07
.79
p
Note. NA = no answer. Q 1: Does the current classification system need to be completely redone? Q 2: Should a 1.5 trunk/hip classification be added? Q 3: Should there be a 4.0 class? Q 4: Should athletes with CP and other motor control coordination impairment be classified with a different system than the current one? Q 5: Should wheelchair rugby be open to any athlete with tetraplegia or tetraequivalent impairment? Q 6: should wheelchair rugby only be open to spinal-cord injuries and other neurological conditions? *p < .05 (Fisher’s exact test).
Yes
Q
All Respondents
Table 2 Answers for Each Question (Q) of the Survey, n (%)
384 Altmann et al.
before having a confirmed sport class (4). Of the 11 respondents with comments about inconsistency, 7 suggested adjustments to the current system and 4 wanted the system completely redone. Of the 4 respondents concerned about cheating, 1 wanted adjustments to the current system and 3 wanted the system completely redone. Of all the responses to this question, only 1 stated complete frustration with the classification system: “Classification is an absolute joke.” For the second question, 67% of all participants stated that the maximum score for trunk impairment should be increased from 1.0 to 1.5. The participants who identified as low- and midpoint athletes selected a scoring change for trunk in a larger majority (75% and 72%, respectively) than the participants who identified as high-point athletes (59%) or those who did not identify as athletes (58%); however, this difference was not statistically significant. Answers to this question were compared between respondents on teams with and without an athlete with minimum to no trunk impairment. This description is presented in Table 3. Of the respondents from a country whose national team lacked a dominant athlete with limited to no trunk impairment, 107 (76%) stated “yes” and 33 (24%) stated “no.” Of the respondents of a country with a national team including such an athlete, 31 (60%) stated “yes” and 21 (40%) stated “no.” The differences between these groups were significant. Questions 3–6 explored athlete eligibility and evaluation of athletes with medical conditions other than SCI. In Question 3, 65% preferred not to add an additional 4.0-point class for less-impaired athletes. There was no significant difference between respondents of different categories. Question 4 explored perceptions of respondents on the effectiveness of the current system for athletes with impairments in motor control and coordination; 67% of all respondents stated that a different classification system should be developed to evaluate these athletes. There was no significant difference between respondents of different categories. Question 5 looked at expanding the list of eligible impairments for wheelchair rugby. The majority of respondents stated that “wheelchair rugby should be open to any athlete with tetraequivalent impairment.” Seventy-two percent of all participants chose “yes.” Significantly more low-point athletes than high-point athletes chose “yes” (Fisher’s exact test, p = .037). The respondents who chose “yes” stated the following in the unstructured responses: Inclusion of athletes with conditions other than SCI is needed to let more athletes in the sport (4 respondents), Table 3 Answers to Question 2 per Country Country without athlete with minimum to no trunk impairment on national team
Country with athlete with minimum to no trunk impairment on national team
A 1.5 trunk/hip classification should be added
21
31
A 1.5 trunk/hip classification should not be added
33
107
Answer
Note. Chi-square = 5.3. p = .021.
Athlete Priorities in Classification 385
the classification system should improve for athletes with health conditions other than SCI (12), the maximum point value for trunk needs to increase (3), and the maximum point value of athletes eligible for wheelchair rugby should not exceed 3.5 (6). Four of the respondents who chose “no” added in the unstructured responses that wheelchair rugby was developed for athletes with SCI. No one gave any other reason for voting “no.” Question 6 examined eligible impairments for wheelchair rugby. When asked if wheelchair rugby should only be open to athletes with SCI and other neurological conditions, 60% of all participants selected “no.” Significantly fewer participants who identified as low-point athletes (51%) selected “no” than participants who did not identify as athletes (64%; Fisher’s exact test, p = .002). In the open statements, 5 respondents declared a need to increase the number of athletes participating in the sport, and 17 thought that athletes should not be excluded from the sport based on medical diagnosis. Six also added that the classification system for athletes with medical conditions other than SCI should be improved, and 1 specifically advocated for the addition of a 1.5 value for the trunk. Four “yes” respondents stated that wheelchair rugby was developed for athletes with SCI and should remain that way.
Discussion Athletes and stakeholders in wheelchair rugby identified four priority areas in a review of the classification system and in classification research for this sport. These areas of concern were (a) minimum eligibility criteria, (b) impact of trunk function on performance, (c) reliability of sport-class decisions, and (d) classification of athletes without SCI. The areas of concern (a), (b), and (d) were consistent with those perceived by classifiers as the most problematic and supported the study hypotheses. Specifically, a majority of the athletes and stakeholders supported adjustments to the current classification system rather than a completely new system. However, there was a significant proportion of the respondents who stated that the classification system needed to be completely redone. Taking into account the confidence intervals of the sample, this minority almost equaled the majority. Therefore, we felt it was insufficient to only take the majority vote into account and we explored the reason for the vote per respondent using the open statements. This exploration showed that the reason for the vote often showed overlap between the group that wanted a completely new system and the group that wanted adjustments. Several respondents expressed concerns about the application of classification. A change or adjustment in the classification system cannot resolve these concerns. For example, an inadequate classification system can be as reliably administered as a valid and evidence-based system. More important, these issues should be addressed in evaluation of classification procedures and in educating and training classifiers and athletes. Out of a total of 302 survey respondents, only 1 formulated a statement in the open response that suggested a deep discontent with classification. Based on the open responses, we were convinced that adjusting the system instead of developing a whole new system was the best choice and did not neglect the opinion of the minority. The recommended adjustments were evaluation of the trunk, with an increased maximum value, and revisions for athletes with impairments other than muscle
386 Altmann et al.
power, the typical impairment in athletes with SCI. The majority of participants stated that athletes should be eligible for wheelchair rugby, regardless of the medical condition causing impairment. However, respondents were not supportive of the idea that athletes with a total point value higher than 3.5 should participate in this sport. Research on the perception of athletes and stakeholders relating to classification in Paralympic sports is rare. Strohkendl (1978, 1996) did extensive work designing a new classification system for wheelchair basketball based on the concept of athlete self-determination. Strohkendl (1996) defined self-determination of athletes: “The players learn to assume responsibility for the system by proposing their own classification, controlling the classification of others, or even by functioning as classifiers” (p. 53). Strohkendl questioned whether “the methods of natural science are appropriate to assess such a complex issue as the physical potential of wheelchair basketball players.” In addition, he claimed that “players know what is limiting and what is helpful when playing wheelchair basketball. Possessing a profound knowledge to sense the physical potential of a typical player of a class, they also succeed in classifying players with disabilities other than paraplegia” (p. 53). Based on these assumptions, Strohkendl created an experience-based wheelchair basketball classification system based on dialogue with athletes in wheelchair basketball who were dissatisfied with the medical classification system used for all sports at that time. However, he provided no details about the athlete group involved or description of the method used for the dialogue. As a result of this absence of descriptions of the sample and methodology, bias may have occurred in a possible nonrepresentative sample of athletes and in an unknown method of recording the athlete responses. Some aspects of this wheelchair basketball classification system seem to be contradictory with the principles of self-determination. According to Strohkendl, classification takes place through fair dialogue and should be as simple as possible. However, implicit knowledge learned by experience is not easy to appreciate by less-experienced athletes and stakeholders and is not open for discussion on an equal level with classifiers. Thus, the provisions of fair dialogue and a simple system may not be present. We found no other published research exploring athletes’ perception of classification. Based on the extensive responses in this study, the opportunity for athletes and sport stakeholders to be involved in developing the classification system seems to be highly valued. Those in wheelchair rugby also concur that athlete involvement is important in the development of evidencebased classification systems. Based on the IWRF’s classification manual (2011), there is no consensus that athletes should propose their own sport class and control the classification of others (p. 55). The potential disadvantage of adopting a fully athlete-centered approach is that athletes have an interest in the game, and thus in classification, which affects the game. If this situation would indeed cause bias, then answers to several questions on the survey, especially Questions 2, 5, and 6, were expected to differ per athlete sport class. Therefore, all answers were analyzed both for the total group of respondents and per athlete sport class. We had expected athlete respondents in the low-point classes to disagree with those in the high-point classes about increasing the maximum score for trunk impairment. This assumption was based on the greater likelihood of impact of the revised trunk-impairment evaluation on athletes in high-point classes, who would more likely see their sport class change or possibly become ineligible (IWRF, 2011). This hypothesis was not confirmed. However, if a national team had one or more
Athlete Priorities in Classification 387
high-point athletes with limited to no trunk impairment, the entire team seemed less supportive of this change in the system. Indeed, if the maximum value for trunk function increased, team lineups would be affected and these athletes might be allowed less time on the court or not play at all. Finding no difference between athletes categorized by sport class can be explained by the representation across all sport classes in the composition of a team. Based on these findings, we concluded that personal interest in the game and consequently in classification plays a role in the athlete responses; however, the interest in the team lineup seemed to play a larger role than personal interest in sport class. We also had expected a difference between categories of respondents based on personal sport class regarding the inclusion of athletes with medical conditions other than SCI. There was a difference in the number of athletes with particular health conditions in the low-point classes (3% with non-SCI) and high-point classes (22% with non-SCI; Altmann et al., 2006), so we expected those in the high-point class to choose “yes.” In contrast to the expectations, athletes in the high-point classes chose “yes” less frequently than the athletes in the low-point classes. This may also be explained by a greater interest in the team lineup than interest in the personal class of the responding athletes. Athletes in the high-point class experience direct competition for lineup positions by those athletes without SCI in the same class, who are perceived to be less impaired. Thus, it would seem to be against the interest of high-point SCI athletes to allow non-SCI athletes to participate. However, the number of athletes in the high-point classes is relatively small; consequently, the number of respondents was low. Possibly, a relatively large proportion of high-point athletes who responded were those with SCI, which would clarify this effect in the response. It is interesting that low-point athletes have a better chance of being on court with an increase in number of high-point athletes, because with the maximum of 8.0 points on court, in any lineup a low-point athlete must be combined with a high-point athlete. Therefore, increasing the number of high-point athletes, regardless of medical condition, is in the interest of low-point athletes. This study demonstrates that the opinion of athletes and stakeholders in Paralympic sport is a valuable tool for evaluating and improving classification systems. Nevertheless, personal interest may play a role in survey responses. This personal interest of (active) athletes and coaches in classification should always be taken into consideration when involving these groups in classification decisions as advocated by Strohkendl (1978, 1996). By systematic assessment of the opinion of athletes and stakeholders, valuable expert information can be made explicit and corrected for bias if necessary. With this method, athlete self-determination is respected, including transparency in classification and providing an opportunity to continue an open and fair dialogue about classification. A representative number of respondents and representation of respondents in each of the seven sport classes controlled for other biases. The group responding to the survey (302) reflected a large sample compared with the population of athletes with an international sport class (628). In addition, the sample was representative based on the distribution of sport classes. Even so, several biases in this research may have occurred. First, a large number of participants did not indicate their role in the sport. Therefore, we analyzed results of the athletes separately from the answers of all other respondents who did not identify their role. There are several possible explanations for why respondents did not identify. Perhaps the nonathletes thought their anonymity would be lost by
388 Altmann et al.
revealing nationality and role in a team and so refrained from sharing these details. However, the ability to determine if a respondent was an athlete was not possible without these details. Language was another possible source of bias because of the overrepresentation of native English speakers. Because questions were in English and translation was only offered on request, nonnative speakers may have been discouraged from responding, consequently creating an overrepresentation of native English speakers in the response. Using survey questions with simple dichotomous answers and including optional open statements was an attempt to control the effect of language on the response rate. Because of the dichotomous questions and the limited number of added open statements, important aspects of the opinions of the respondents may have been missed. This study is possibly the first time a systematic assessment of this type and scope has been done involving athletes and stakeholders in revision or development of a classification system in Paralympic sport. Although classification is moving toward an evidence-based foundation, this extensive goal can only be accomplished one step at a time. This research completed the first three phases of the dialogue model (Abma & Broerse 2010). The results were presented to the general assembly of the IWRF in 2010, thus completing the integration phase, the fourth phase of the dialogue model. A discussion was conducted with representatives of all IWRF member countries to determine the agenda for adjustments in the classification system and to set the start of a research program to achieve this agenda. The next steps will include the programming phase and the implementation phase, which will consist of adjustments in the evaluation of the trunk (with an increased maximum value) and revisions for athletes with impairments other than muscle power (the typical impairment for athletes with SCI). The first step in the implementation phase is in process and examines the extent of trunk impairment and the impact on sport-specific activities in wheelchair rugby, including both a systematic literature review and conducting experimental studies. In the experimental studies, athletes with medical conditions other than SCI, as well as those with incomplete SCI, will be included. The ultimate goal is to develop an evidence-based classification system for all eligible impairments in wheelchair rugby that determines the impact of eligible impairments on sport-specific activities in wheelchair rugby. The aim is to develop a system that is transparent, reliable, and accepted by athletes and others involved in wheelchair rugby. Acknowledgment This research was supported by the International Wheelchair Rugby Federation (IWRF) by facilitating the access to the survey to all athletes and stakeholders in wheelchair rugby
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