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Topical Review: Understanding Vision Impairment and Sports Performance

through a Look at Paralympic Classification

Article in Optometry and vision science: official publication of the American Academy of Optometry · July 2021
DOI: 10.1097/OPX.0000000000001723

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 REVIEW

Topical Review: Understanding Vision Impairment and Sports

Performance through a Look at Paralympic Classification
Downloaded from http://journals.lww.com/optvissci by OmQMfJQKcoJCmBc1ed32IUPpLovMOK8L/DmN42/i0TI5Pxf2QQrbWa72bDeQxuhMLhshbMcrLLAdBqQZdiRkZP3Ut9ZGeTeyOidtyPDxhNoLrkXzPW7WGjsMrORfEHlb+pV/ooUhIVRGXaQqVlN1vX+Ex0Se+MlrA2ks2qyImFs= on 08/03/2021

Robert Chun, OD, FAAO,1* Marieke Creese, BKI,2 and Robert W. Massof, PhD, FAAO1

SIGNIFICANCE: To provide meaningful competition that is equitable for Paralympic athletes, classification systems
are vital to determine which athletes are eligible to compete in adapted forms of sports and to group athletes for
competition. Our discussion has important implications to inform how we should approach visual function assess-
ment in sports performance.
Sport participation positively benefits individuals with low vision. In particular, adapted sports exist to provide peo-
ple with visual disabilities an avenue for participating in recreational activity. High-performance low-vision athletes
can participate in Paralympic sports but need to be properly classified based on the severity of their vision impair-
ment. The model for Paralympic classification was initiated by Sir Ludwig Guttmann in 1952 in a rehabilitation
clinic for soldiers with spinal cord injuries. Today, the International Paralympic Committee mandates that interna-
tional sports federations develop evidence-based sport-specific classification systems to ensure that eligible dis-
abled athletes have an opportunity for meaningful competition. With the current classification system, only Author Affiliations:
1
visual acuity and visual field measures are considered to determine an athlete's eligibility to compete, leaving room Wilmer Eye Institute, School of
to expand our understanding of visual function requirements for individual sports. In this topical review, we discuss Medicine, Johns Hopkins University,
the origins of Paralympic sports, limitations of current classification methods, and requirements toward achieving Baltimore, Maryland
2
evidence-based sport-specific evaluation systems. School of Optometry and Vision
Science, University of Waterloo, Ontario,
Optom Vis Sci 2021;98:759–763. doi:10.1097/OPX.0000000000001723 Canada
Copyright © 2021 American Academy of Optometry *robert.e.chun@gmail.com

The field of low vision rehabilitation has demonstrated the nega-
tive impact of vision impairment on one's psychosocial well-being1–3
and the significant economic burden4 of visual disability. Given the
strong association between vision impairment and an individual's
psychological status, it is no surprise that sports and recreational ac-
tivities have emerged as a major outlet for visually impaired individ-
uals to optimize the quality of their lives in the context of their visual
disabilities. Prior work has confirmed the significant value of sports
participation and involvement in recreational activities among visu-
ally impaired5 and physically disabled athletes,6 which has moti-
vated the work of vision scientists7–10 to advance our knowledge
in sports classification research for athletes competing at the highest
levels. Individual sports federations and governing bodies like the In-
ternational Paralympic Committee and International Blind Sports
Federation have rapidly grown in terms of membership participation,
funding, and visibility.
Paralympic sports provide individuals with disabilities the op-
portunity to participate in many sporting events across the world.
Athletes are allowed to compete in Paralympic events if they are de-
termined to have an eligible physical, intellectual, or vision impair-
ment. With increasing participation and investment to develop the
skills of visually impaired athletes, sports classification research
has begun to emerge to advance the methods for how Paralympic
sports are organized. Specifically, the International Paralympic Com-
mittee has focused its attention on ensuring that all international
sports federations are working toward applying sport-specific,
evidence-based classification methods.11 With the rapid growth
of athlete participation and global visibility of high-performance
athletes with disabilities, there remains an urgent need that will require
increased collaboration among clinicians, researchers, athletes, and
sport professionals to continue our efforts for implementing
evidence-based classification guidelines.
Here, we focus our attention to Paralympic sports classification
methods as it pertains to vision and will (1) present the basic con-
cepts of visual impairment classification for Paralympic sports, (2)
discuss the major challenges and limitations in low vision sports
classification methods and research, and (3) review the systematic
approaches to improve our current methods.
HISTORY
In 1952, German neurologist Sir Ludwig Guttmann had a vision
to rehabilitate his patients with spinal cord injuries through sport-
ing activities at Stoke Mandeville Hospital (United Kingdom).12
He saw the detrimental psychological impact the physical disabil-
ities had on his patients and considered sports a therapeutic form
of rehabilitation for his physically disabled patients. Progressive
in his thinking for the time, Guttmann saw the importance of involv-
ing his patients in adapted forms of recreational activities like wheel-
chair basketball to improve the quality of their lives. In 1948, his
efforts gained momentum when he strategically organized the Na-
tional Stoke Mandeville Games to coincide with the Summer Olym-
pics hosted in London. This began the cascade of events leading to
the birth of the official Paralympic Games of 1960 in Rome. Today,
the International Olympic Committee and International Paralympic
Committee have established a formal cooperation agreement, which
organizes the Olympic and Paralympic Games back-to-back in the
same host city. The Paralympic movement continues to garner global
visibility and support and has led to the United States acknowledging

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Vision Impairment/Paralympic Sports Performance — Chun et al.
the importance of including Paralympic athletes under one umbrella
as the United States Olympic & Paralympic Committee.13
As of 2016, the Paralympic games have grown to include 22
summer and 5 winter sports among athletes with physical, intellec-
tual, and vision impairments. With its origins in athletes with spinal
cord injuries, Paralympic sports began with a medical classification
system whereby athletes with the same medical diagnosis were
grouped together to compete against each other. With time, as the
scientific community was called upon to develop evidence-based
procedures,7,9,14–19 sports classification has evolved from a medical
classification system to a functional categorization of impairments.
Thus, athletes with different eye pathologies are allocated into dif-
ferent sports classes according to their visual function.
Each participating nation and international sports federation
has a body of national and international visual impairment classifiers
who are trained in applying standardized classification methods and
procedures established by the International Paralympic Committee
and International Blind Sports Federation. Currently, there are 48
optometrists and ophthalmologists representing six continents who
are certified as international classifiers by these two main governing
bodies for visual impairment sports. There are many more national
classifiers who work in a domestic capacity who have the potential
to be called upon to join the international pool of classifiers. In the
United States, there are currently two international and six national visual
impairment classifiers who are active in Paralympic sports classification.
WHAT IS PARALYMPIC SPORTS CLASSIFICATION?
Athlete classification in Paralympic sports is defined as “the pro-
cess of grouping athletes into sport classes according to how much
their impairment affects fundamental activities in each specific
sport. The purpose of classification is to ensure that the impact of
eligible impairment in each event is minimized.”11
The minimum impairment criteria were adapted from the World
Health Organization's guideline for low vision and blindness.20 Cur-
rent methods for visual impairment classification serve to answer
the following salient questions:
1. Does the athlete have a vision impairment to compete in a
Paralympic sport?
2. Does the athlete's eligible impairment meet the minimum
impairment criteria for the sport?
3. Which sport class describes the athlete's vision impairment
most accurately?
To date, our classification system for Paralympic visual impair-
ment sports is not sport specific whereby the same visual criteria
to determine eligibility, minimum impairment criteria, and classifi-
cation category are applied to nearly all visual impairment sports.
With exception to shooting (as the only sport-specific system),9 visual
impairment classification relies solely on visual acuity and visual field
measurements to determine eligibility and a sport class defined by
three levels from least to most impaired: B3, B2, and B1 (Table 1).
Athletes must meet the minimum impairment criteria by either visual
acuity or visual field loss using approved testing methods. When an
athlete happens to meet the eligibility criteria with both visual acuity
and visual field cutoffs, the most impaired classification level is allo-
cated. For instance, if an athlete with glaucoma has logMAR 1.2
(B3) but 5° total visual field (B2), he/she would qualify for a B2 clas-
sification using the more impaired class involving visual fields (see
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TABLE 1. Current system to determine vision impairment
classification for Paralympic sports
Classification
levels VA VF
B1 logMAR >2.6 (>20/7962) None
B2 logMAR 1.5–2.6 VF diameter <10°
(20/632–20/7962)
B3 logMAR 1.0–1.4 10° ≤ VF diameter
(20/200–20/502) < 40°
Not eligible logMAR <1.0 (<20/200) VF diameter ≥40°
B1, B2, B3 = ordinal numbering of groups from most to least
impaired.21 VA = visual acuity; VF = visual field.
Ref. 22 for additional Paralympic guidelines involving the verification
process of an eligible impairment in the athlete evaluation).
Limitations of Current Classification Method
Although visual acuity and visual field measures are key determi-
nants of visual function, there are several methodological shortcom-
ings of applying one visual standard across all Paralympic visual
impairment sports in the current approach15,23:
• The activity limitations from vision impairment are likely dif-
ferent for each sport, which should result in different mini-
mum impairment criteria.
• The visual requirements for individual sports vary and may re-
quire additional tests beyond visual acuity and visual field alone
to assess visual function related to individual sports (e.g.,
contrast sensitivity, visual reaction, and visual search).
• The minimum impairment criteria and classification levels may
require newly developed or adapted methods of visual function
testing.
Recent work has already begun to address these limitations, in-
cluding one study that demonstrated the need to incorporate con-
trast sensitivity testing for shooting.9 Another preliminary study
showed the weak association of visual acuity alone to predict run-
ning performance in athletics (track and field).8 As for new methods
of visual testing, Roberts et al.10 demonstrated the potential value of
global motion perception testing for skiers. Thus, we seek to address
these major limitations and define sport-specific minimum impair-
ment criteria in addition to evidence-based classification levels to ul-
timately ensure fair competition among competing athletes with
varying severities of vision impairment. Defining the minimum im-
pairment criteria for each sport will require significant work to (1)
identify which visual function measures and factors are most rel-
evant to determine meaningful disability16 and (2) determine
appropriate levels of classification to distinguish distinct levels of
impairment. Mann and Ravensbergen16 and Ravensbergen et al.17,23
proposed a systematic approach to accomplish the following by
studying athlete performance in the unadapted form of the sport
to answer question 1 and examining athlete performance in the
adapted form to answer question 2.
In brief, we discuss the significance of the adapted and unadapted
forms of sports in using this approach. Paralympic visual impairment
sports like judo, swimming, and athletics have adapted rules of
760

competition, so athletes are able to compete with certain modifica-
tions or accommodations. For instance, in athletics, the most im-
paired group of runners (T11) run with a guide, and those in the
next impaired class (T12) have the option of running with a guide.
In blind soccer (five-a-side football), all athletes wear a blindfold to
provide a more equitable level of impairment. There remains con-
troversy about whether these adaptations or modifications are in
fact creating a more equitable environment. Nonetheless, Mann
and Ravensbergen16 note that determining the proper method or
number of sport classes (levels of impairment) should be based
on investigating the impact on performance in the adapted form
of the sport. In contrast, the minimum impairment criteria should
be based on the idea of determining the “minimum level of impair-
ment that has an impact on sport performance”11,21 by consider-
ing the unadapted form of the sport, in which normally sighted
individuals participate.
In addition, investigating the utility of using a global disability
measure to signify the overall impact of vision impairment in each
sport may be useful to move toward a sport-specific visual classifi-
cation method. Namely, it is possible that a composite impairment
measure be derived from the battery of visual function measures or
sport-specific tests to convey overall impairment or disability for a
particular sport. Colenbrander24 derived a measure known as the
visual system impairment rating using visual function measures (vi-
sual acuity and visual field) to determine statistical estimates for
how a visually impaired person functions in vision-related activities
of daily living such as reading, writing, orientation and mobility, and
face recognition. In assessing disabilities in unique populations and
circumstances, he points out that “an ability profile is needed to dif-
ferentiate between various abilities.”25 We discuss these parallels
further in the next section.
Lastly, for visual impairment classifiers, it becomes particularly
difficult to confirm ineligibility in athletes having visual acuity loss
that barely meet the logMAR 1.0 (20/200) cutoff despite an ob-
servable eye pathology. For instance, patients with ocular albinism
will often find themselves in this scenario where there exists an
eligible eye diagnosis with associated vision impairment, but their
vision loss is not severe enough to compete. It is likely that the
unique visual impairments associated with albinism including cen-
tral vision loss and marked light sensitivity may qualify using differ-
ent minimum impairment criteria from what is applied today if
other factors like severity of light sensitivity were considered for indi-
vidual sports. The International Paralympic Committee has recognized
these major limitations in recent years and placed substantial empha-
sis on the movement toward developing better sport-specific classi-
fication criteria guided by research.
SYSTEMATIC APPROACH TO A SPORT-SPECIFIC
CLASSIFICATION MODEL
To begin, we illustrate the parallels that exist in moving to-
ward a sport-specific classification model by briefly bringing at-
tention to the previous work that established the relationships
between vision impairment and activities of daily living performance
for reading,26–30 driving,28,31,32 and mobility,33,34 among other ma-
jor activities of daily living.24,32,35–37 In addition, other major organi-
zations like the World Health Organization20 and Social Security
Administration have sought out to derive visual impairment and dis-
ability criteria to determine blindness as it relates to disability. Social
Security Administration allows one to define statutory blindness using
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Vision Impairment/Paralympic Sports Performance — Chun et al.
a visual efficiency score derived from visual acuity and visual field
loss.38 These cutoffs were derived from investigating the impact of dis-
ability on major activities of daily living. Although we can possibly
extrapolate these derivation methods for defining sport-specific
classification guidelines, these criteria may not hold true in defin-
ing eligibility guidelines for individual sports and will require sub-
stantial work to move toward a sport-specific model for vision.
Low vision specialists are faced with addressing these func-
tional deficits of patients with rehabilitation strategies that will be
most effective for that individual patient's goals in the setting of
other comorbidities (cognitive, psychological, physical). Still, there
may be other barriers that may impact the overall outcome of a
patient's vision rehabilitation including one's socioeconomic status
or personal preferences,39 but nonetheless, proper vision rehabilita-
tion focuses on the individual's goals for performing daily activities
that are unique to that patient. Prior work establishing the associa-
tions between the various aspects of visual function and functional
abilities of activities of daily living help guide us in properly targeting
interventions to effectively improve specific aspects of function.
In 1995, Massof et al.40,41 defined a systematic approach to
low vision rehabilitation by (1) defining one's overall functional life
state through a hierarchal framework known as the activity break-
down structure35 and (2) mapping visual function measures (visual
acuity, visual field, contrast sensitivity) to various functional do-
mains (reading, mobility, visual information processing, and visual
motor). Coupled with the work of Colenbrander24,42 in deriving
functional vision estimates, these seminal investigations have
guided our approach to systematically studying visual disability and
its impact on performance for specific activities of daily living and
may not be that different from how we examine the role of visual
function in sports performance. Tweedy15,43 describes an analogous
approach by mapping Paralympic sport activity to specific domains
of the hierarchal structure defined by the International Classification
of Functioning, Disability, and Health. This work further informed
others like Ravensbergen et al.23 to systematically assess the visual
requirements for individual sports like swimming by breaking down
performance into individual components. Nonetheless, it is this
question of defining the specific visual requirements for participat-
ing in a sport (ability profile) to ultimately determine which visual
function measures are most pertinent for individual sports. This be-
comes especially important in reconciling the impact of different
morphologies of visual field loss (e.g., nonconcentric and noncon-
tinuous) on performance in individual sports. For example, one can
hypothesize that inferior visual field loss may impact skiers more
than shooters.
In addition to visual acuity and visual field, it is likely that existing
visual tests like contrast sensitivity, brightness acuity testing, and
stereopsis, among others, may be useful in establishing minimum
impairment criteria for certain sports. Moreover, for some sports,
other higher-order factors relating to visual processing in a dynamic
environment like visual search,44 fixation stability,45 visual atten-
tion,46 sway/postural stability,47 dynamic visual acuity,48 and mo-
tion perception49 will be important to assess especially when time
is a factor in determining performance. Furthermore, other concepts
like time error (speed accuracy) trade-off50 and the role of visual
function measures in static versus dynamic tasks51 will be important
to consider when systematically defining visual function require-
ments for individual sports.
Other questions that remain unanswered deal with the notion of
how age of vision impairment acquisition (duration of vision impair-
ment) and rates of disease progression impact sports performance.
761
Vision Impairment/Paralympic Sports Performance — Chun et al.

We cannot begin to tackle some of these questions without calling
upon prior work characterizing the neuroplasticity seen with visu-
ally impaired populations, which demonstrate the recruitment of
other sensory pathways in adapting to vision impairment among
congenitally blind versus late-onset vision loss.52 In certain scenarios,
we cannot assume that those Paralympic athletes with congenital
vision loss are at a disadvantage.16 On the contrary, these patients
have quickly adapted and developed more heightened auditory and
tactile senses over time through neuroplastic pathways. Shooting is
one sport where these patients may have an advantage where audi-
tory cues provide feedback to the athlete.53 There are likely privileged
paths in the brain that allow individuals to efficiently adapt their func-
tional ability and performance after permanent vision loss, but this will
require additional collaborative efforts among clinicians, vision
scientists, and neuroscientists to uncover the effects of these
neurosensory adaptations. Ultimately, these findings will guide
individual sports federations to use adaptations and modifications
more effectively for athletes to minimize the effect of vision impair-
ment on overall performance.
In systematically addressing some of these major issues, we are
ultimately faced with how to assess visual performance using con-
ventional visual function measures in addition to new psychophys-
ical methods to simulate visual function in a more natural or
real-world competition. The goal is not to use all visual tests possi-
ble in the classification of visual impairment athletes but, rather, to
identify the most relevant battery of assessments that directly cor-
relate to visual performance for a specific sport. One study found
that the most significant predictor of mobility performance among
patients with AMD was the size of a binocular central scotoma.54
Such investigations are particularly relevant to show the importance
of using binocular (versus monocular) measures in the assessment of
functional performance for some sports.
CLASSIFICATION CHALLENGES
The rapid growth of the Paralympic movement has raised the
stakes for Paralympians who have a chance at international recog-
nition in addition to monetary awards. Unfortunately, on the rare
occasion, athletes may be tempted to cheat or engage in “inten-
tional misrepresentation.”11,55 This is when athletes feign their di-
agnosis or severity of their vision impairment to compete in a sport
or sport class. Diagnoses like amblyopia, high myopia, and even
those that are associated with disorders of the visual pathway can
become challenging to distinguish from athlete misrepresentation
because we are limited to mainly relying on electrophysiology test-
ing to confirm an eligible impairment. Also, there are instances
when the severity of an athlete's vision impairment is in question
(e.g., B3 vs. B2 or B2 vs. B1), and for the same reason, we are lim-
ited in available testing or validated psychophysical methods for
confirming the severity of vision impairment when there exists a
motivation to malinger. For example, testing with other methods
like an optokinetic drum and tangent screens has been considered
but provides limited information in instances where an accurate
approximation of visual acuity or visual field is critical to determine
not only eligibility but also a visual impairment classification.
On-site evaluation with electrophysiology experts who can prop-
erly assess visual potential with pattern visual evoked potentials
and eletroretinograms22,56 in addition to recently improved methods
for visual acuity assessment55,57 has improved classification methods
for detecting and preventing athlete misrepresentation. For example,
Ravensbergen et al.55 have demonstrated how high variability in visual
acuity estimations using the tumbling E optotypes of Berkeley Ru-
dimentary Vision Test can be one way to detect intentional misrep-
resentation.57 More of these carefully designed investigations that
refine the psychophysical methods of accurately determining re-
peatable visual acuity and visual field estimations for sports classi-
fication will indeed minimize opportunities for athletes to malinger.
CONCLUSIONS
In this article, we reviewed the basic concepts and purpose of
vision impairment classification methods in Paralympic sports.
We recall Sir Ludwig Guttmann's vision to use sports to rehabilitate
individuals with disabilities to highlight the significant impact cli-
nicians and researchers can have on patients coping with perma-
nent vision loss by involving their patients in competitive sports
and recreational activities. We recognize the challenge of providing
effective vision rehabilitation care when patients are struggling to
deal with the psychosocial impact of their disabilities caused
by permanent vision loss. Thus, when patients are not particu-
larly receptive to professional counseling to cope with their vision
changes, sports and recreational activities should not be overlooked
especially for youth with low vision.
We presented the major knowledge gaps involving Paralympic
sports classification among visually impaired athletes, which has
broader implications for the field of low vision rehabilitation and vi-
sion science. As we advance toward a sport-specific classification
system for Paralympic competition, we will gain a better under-
standing for how athlete performance for individual sports will be
impacted by unique visual deficits, in addition to identifying new
and better methods for testing visual function as it relates to sports
performance and recreational activities. Moreover, by understand-
ing the specific visual requirements of individual sports, we can
better target interventions, identify, and properly implement solu-
tions to minimize the impact of visual impairment for low-vision
athletes, and develop better clinical tests and psychophysical mea-
sures for sports vision. Thus, we anticipate increased familiarity
and growing participation among optometrists, ophthalmologists,
vision scientists, and sports professionals to advance this area of
sports vision, so our visually impaired patients will continue to have
the opportunity to compete and be properly recognized for their
achievements alongside their fully sighed Olympic peers.

ARTICLE INFORMATION Conflict of Interest Disclosure: None of the authors have
reported a financial conflict of interest.
Submitted: September 30, 2020 The authors' views expressed in this review are their own
and do not represent the views of the International
Accepted: January 18, 2021 Paralympic Committee.
Funding/Support: None of the authors have reported funding/ Author Contributions: Supervision: RWM; Writing – Original
support. Draft: RC, MC; Writing – Review & Editing: RC, MC, RWM.
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