Table 2.

Practical recommendations for Paralympic athletes competing at Tokyo 2020 to reduce thermal strain.

Type of recommendation	Advice
Education	Education on the signs and symptoms of heat illness should be paramount for coaches and support staff, to recognize when an athlete needs to stop, be removed from the environment and/or cooled with an appropriate cooling method. Guidance on how to prevent heat-related illnesses when watching the Paralympics in outdoor venues should be given to spectators, especially those with an impairment. Similar advice should be given to support and coaching staff.
Health and fitness	Medications and sleep deprivation may affect an athlete’s heat tolerance [134], especially as symptoms of insomnia can be up to 70% greater in Paralympic athletes [144]. Therefore, when the athlete is traveling or competing in a warm environment, appropriate use of medication should be addressed plus a structured sleep routine. Body regions which are prone to skin breakdown due to contact with sports equipment and the accumulation of sweat should be checked frequently to avoid skin-related complications. Coaches and athletes should ensure that athletes are aerobically fit to improve the athlete’s heat tolerance. This is especially important for skilled sports, where high levels of cardiovascular fitness may not be a key determinant of sporting success.
Environment	Avoid exposure to the sun where possible and use sun cream appropriately to lessen the risk of sunburn and the detrimental effect on local sweating ability. Athletes with an intellectual impairment may require additional supervision and guidance regarding hydration advice and avoidance of sun exposure. Although some athletes compete indoors, they are still likely to be exposed to the heat through traveling and moving around the Paralympic village. For instance, it has been reported that athletes increase their step count by as much as 83% when in the Paralympic village compared to daily living [143]. Thus, all athletes should adapt fluid practices and strategies to combat the heat.
Cooling strategies/fluid and nutritional practices/acclimation	Support staff must implement an individualized approach refining an athlete’s cooling strategy according to the athlete’s needs and the sporting demands. Practice any strategies employed prior to competition, ideally, simulating as closely as possible the “real-world” sporting environment. An acclimation strategy must be considered for athletes who compete outdoors. Even athletes with an SCI may be able to achieve partial acclimation. Awareness of suppressed appetite in the heat and during long haul travel should be considered and nutritional practices adapted accordingly.
Technology	Wearable technology may be beneficial during training to determine an individualized strategy when competing in the heat. The benefit of the wearable must override any potential increase in heat strain from an additional clothing layer and be suitable for the individual athlete.
Policy	Additional water and first aid stations may be required for specific sports.