Results: Thirty-eight systematic reviews (2012-2026) were included across five domains. Injury evidence showed a substantial, heterogeneous burden, with recurrent upper-limb and shoulder problems in wheelchair and sitting sports. Physiological and training evidence showed sport-, impairment-, sex-, and protocol-related variation; supplementation, sleep, and recovery evidence remained limited. Testing and classification reviews showed stronger evidence for reliability than for validity, responsiveness, or class-specific interpretation. Biomechanical and technology studies highlighted task- and equipment-dependent performance, whereas psychological and system-level reviews identified psychosocial, coaching, accessibility, financial, and infrastructural determinants, although evidence was frequently cross-sectional or indirect. ROBIS rated 11 reviews low risk, 23 high risk, and 4 unclear; AMSTAR 2 confidence was moderate in 2, low in 3, and critically low in 5. Primary-study overlap was moderate (CCA 7.6%). Secondary analyses estimated injury prevalence at 41.9% and incidence at 13.4 per 1,000 athlete-days, both with wide prediction intervals; sport-specific normalized VO₂peak estimates ranged from 17.4 to 45.3 mL/kg/min.

Conclusions: The evidence base is broad but methodologically uneven and strongly context-dependent. Greater standardization and sport- and impairment-specific research are needed to improve comparability and relevance.

Paralympic sportPara sportumbrella reviewsecondary meta-analysisVO₂peakinjuryclassificationbiomechanicsassistive technologyperformance testingevidence mapping

funding

This research received no external funding.

ethics

Not applicable; this study synthesized published literature and did not involve new human-participant data.

consent

Not applicable.

data-availability

The de-identified processed datasets, complete analysis tables, and analysis code supporting the findings of this study are available from the corresponding author upon reasonable request.

competing-interests

The authors declare no commercial, financial, or other relationships that could be construed as a potential conflict of interest.

credit

Nicola Luigi Bragazzi: Conceptualization; Methodology; Formal analysis; Visualization; Writing – original draft; Writing – review & editing. Morteza Taheri: Screening; Data curation; Validation; Writing – review & editing. Carlo Trompetto: Methodology; Validation; Supervision; Writing – review & editing. Luca Puce: Conceptualization; Supervision; Project administration; Writing – review & editing.

acknowledgements

The authors have no acknowledgements to report.

trial-registration

PROSPERO CRD420261387208.

ai-disclosure

Generative AI tools were used only for editorial preparation and formatting support. The authors reviewed and approved the final content and take full responsibility for the work.

Protocol and registration: PROSPERO CRD420261387208

Contents

Supplementary Table S1. Included systematic reviews

Supplementary Table S2. ROBIS and AMSTAR 2 appraisal summary

Supplementary Table S3. Primary-study overlap and corrected covered area

Appendix S1. Database search strategies

Appendix S2. Full-text exclusions with reasons

Appendix S3. Reproducibility specifications for secondary analyses

Supplementary Table S1. Included systematic reviews

The included-review corpus comprises 38 systematic reviews and reconciles with the final domain totals reported in the main manuscript.

ID	Review	Primary domain	Title	Evidence base / sample
R01	Becerra-Patiño et al., 2026	Biomechanics, Equipment & Sport-Specific Performance	Identification of Performance Variables in Blind 5-A-Side Football: Physical Fitness, Physiological Responses, Technical–Tactical Actions and Recovery Variables: A Systematic Review	quantitative studies with heterogeneous samples across physical/physiological, technical–tactical and recovery domains.
R02	Ferreira et al., 2023	Biomechanics, Equipment & Sport-Specific Performance	Current status of sport performance in Boccia: systematic review of the literature	669 documents were initially identified using “Boccia”; when “Performance” was added, results were reduced to 26 documents.
R03	Fiorese et al., 2020	Biomechanics, Equipment & Sport-Specific Performance	Biomechanics of starting, sprinting and submaximal running in athletes with brain impairment: A systematic review	8 studies, corresponding to 9 eligible articles; 100 runners with brain impairment: 78 males and 22 females, aged 18–38 years.
R04	Garcia-Carrillo et al., 2025	Biomechanics, Equipment & Sport-Specific Performance	The science of adapted throws: a systematic search and narrative evidence synthesis	19 studies including 345 para-athletes across 14 World Para Athletics sport classes, mainly seated throwers from F32–F58 and limb-deficient/prosthesis-related classes F61–F63.
R05	Liu et al., 2025	Biomechanics, Equipment & Sport-Specific Performance	Emerging assistive technologies in Paralympic sports: a systematic review	42 studies from 18 countries, selected from 929 records.
R06	Oliveira et al., 2023	Biomechanics, Equipment & Sport-Specific Performance	Para Powerlifting Performance: A Systematic Review	9 included studies involving 157 Para powerlifting athletes: 101 men, 28 women and additional participants with sex not declared/undefined.
R07	de Oliveira Silva et al., 2025	Biomechanics, Equipment & Sport-Specific Performance	Analysis of the kinematic pattern of free throw by wheelchair basketball athletes: a systematic review	7 quantitative cross-sectional studies; 216 male wheelchair basketball athletes, mostly national-team/professional-level players; 92.59% were national-team players.
R08	Heyward et al., 2017	Injury & Health Constraints	Shoulder complaints in wheelchair athletes: A systematic review	13 studies were included from 197 search results after duplicate removal and screening.
R09	Jodar-Boixet et al., 2025	Injury & Health Constraints	Assessing musculoskeletal complaints in para-athletes: A systematic review and critical appraisal of available Patient-Reported Outcome Measures	Six articles were included.
R10	Kunorozva et al., 2024	Injury & Health Constraints	The epidemiology of eye illness in Para athletes in the Winter and Summer settings: a systematic review	Eight studies were included.
R11	Luijten et al., 2023	Injury & Health Constraints	Sports-Related Health Problems in Para-Sports: A Systematic Review With Quality Assessment	64 studies met the inclusion criteria from 3006 records.
R12	Moraes et al., 2025	Injury & Health Constraints	Sports injuries in sitting volleyball athletes: a systematic review	10 studies were included, published between 2000 and 2019, from six countries: Brazil, United States, Poland, South Africa, Rwanda and Iraq.
R13	Pinheiro et al., 2021	Injury & Health Constraints	Prevalence and incidence of injuries in para athletes: a systematic review with meta-analysis and GRADE recommendations	42 studies were included from 4092 records.
R14	Santos Silva Lopes et al., 2022	Injury & Health Constraints	Profile of musculoskeletal injuries in the parasport: A systematic review	31 studies including 17,608 participants were included from 27,798 records.
R15	Singh et al., 2024	Injury & Health Constraints	Concussions in Paralympic Sports: A Systematic Review	13 studies included.
R16	Sá et al., 2022	Injury & Health Constraints	Injuries in Wheelchair Basketball Players: A Systematic Review	Eight quantitative studies were included, involving 753 wheelchair basketball players of both sexes; 462 were men.
R17	Ahmadi & Uchida, 2021	Performance Assessment, Testing & Classification	Place of the gold standard isokinetic dynamometer in Paralympic sports: a systematic review	981 records were initially identified; 10 studies were finally included.
R18	Altmann et al., 2022	Performance Assessment, Testing & Classification	Objective Measurement of Ball-Handling Proficiency in Wheelchair Sports: A Systematic Review	22 articles met the minimum methodological-quality threshold and were included in the synthesis.
R19	Ferreira da Silva et al., 2022	Performance Assessment, Testing & Classification	Wheelchair skill tests in wheelchair Basketball: A systematic review	23 studies were included, involving 838 wheelchair basketball athletes.
R20	Gavel et al., 2023	Performance Assessment, Testing & Classification	Reliability of anaerobic and aerobic mobility performance tests used in wheelchair rugby, wheelchair basketball and wheelchair tennis: A systematic review	21 studies; 317 participants in WCB, wheelchair rugby and wheelchair tennis.
R21	Hutchinson et al., 2021	Performance Assessment, Testing & Classification	Measures of impairment applicable to the classification of Paralympic athletes competing in wheelchair sports: A systematic review of validity, reliability and associations with performance	23 studies were included.
R22	Luarte et al., 2022	Performance Assessment, Testing & Classification	Most frequent tests in the literature for the evaluation of physical qualities in elite level Paralympic wheelchair basketball: a systematic review	The search identified 270 records.
R23	O’Connor et al., 2022	Performance Assessment, Testing & Classification	Assessment of muscle strength in para-athletes: A systematic review of observational studies	30 studies; wheelchair sports represented 23/30 studies (76%).
R24	Sá et al., 2023	Performance Assessment, Testing & Classification	Evidence-Based Classification in Wheelchair Sports: A Systematic Review	10 studies were included from 141 initially identified records.
R25	Wileman et al., 2025	Performance Assessment, Testing & Classification	Guiding Evidence-Based Classification in Para Sporting Populations: A Systematic Review of Impairment Measures and Activity Limitations	51 articles were included.
R26	Araujo et al., 2025	Physiological, Nutritional & Training Determinants	Sleep Quality and Specific Characteristics of Different Types of Impairments in Paralympic Athletes: an Updated Systematic Review	110 records were retrieved: 23 from EMBASE, 17 from PubMed, 32 from Scopus, 7 from SPORTDiscus and 31 from Web of Science.
R27	Baumgart et al., 2018	Physiological, Nutritional & Training Determinants	Peak oxygen uptake in Paralympic sitting sports: A systematic literature review, meta- and pooled-data analysis	57 studies reporting VO₂peak values from 771 athletes across 14 Paralympic sitting-sport disciplines.
R28	Becerra-Patiño et al., 2025	Physiological, Nutritional & Training Determinants	Differences in Anthropometric and Body Composition Factors of Blind 5-a-Side Soccer Players in Response to Playing Position: A Systematic Review	10 studies were included, with a total sample of 168 athletes.
R29	Feitosa et al., 2023	Physiological, Nutritional & Training Determinants	Monitoring oxygen uptake, blood lactate and heart rate in swimmers with physical impairments: A systematic review	10 studies involving 142 swimmers with physical impairments were included.
R30	Palacín Artigosa et al., 2022	Physiological, Nutritional & Training Determinants	Effects of Goalball on Balance: A Systematic Review	85 articles were initially retrieved.
R31	Perret & Flueck, 2016	Physiological, Nutritional & Training Determinants	Supplementation and Performance in Spinal Cord-Injured Elite Athletes: a Systematic Review	618 records were initially identified; 566 were excluded as unrelated to the topic; 52 studies were retrieved in detail; 47 were excluded; 5 studies met all inclusion criteria.
R32	Perret, 2017	Physiological, Nutritional & Training Determinants	Elite-adapted wheelchair sports performance: a systematic review	Elite/trained wheelchair sport athletes; 6 studies on respiratory training, 2 cooling, 7 equipment adaptations.
R33	Shaw et al., 2021	Physiological, Nutritional & Training Determinants	Dietary Supplementation for Para-Athletes: A Systematic Review	15 articles involving 311 participants were included.
R34	Fadian et al., 2025	Psychological, Social & System-Level Factors	The development of various fields of Paralympic sports: a systematic review	The review reports that 947 articles met initial criteria, 759 remained after screening, and 24 articles were finally selected for qualitative/meta-synthesis.
R35	Ferreira et al., 2024	Psychological, Social & System-Level Factors	Burnout syndrome and coping strategies in athletes with disabilities: a systematic review	157 records were identified; 25 duplicates were removed; 132 records were screened; 8 studies were included.
R36	Jefferies et al., 2012	Psychological, Social & System-Level Factors	The Paralympic athlete: a systematic review of the psychosocial literature	2,269 citations were identified from the five databases.
R37	Mira et al., 2023	Psychological, Social & System-Level Factors	Well-Being, Resilience and Social Support of Athletes with Disabilities: A Systematic Review	287 studies were identified; after duplicate removal and screening, 39 articles were assessed for eligibility and 27 studies were included.
R38	Rodríguez Macías et al., 2022	Psychological, Social & System-Level Factors	The Sport Training Process of Para-Athletes: A Systematic Review	19 articles were included.

Supplementary Table S2. ROBIS and AMSTAR 2 appraisal summary

ROBIS classified 11 reviews as low risk of bias, 23 as high risk, and 4 as unclear. AMSTAR 2 was applicable to 10 reviews: 0 were rated high confidence, 2 moderate, 3 low, and 5 critically low. Agreement before consensus was 89.5% (Cohen’s kappa = 0.78). ROBIS and AMSTAR 2 judgments were completed independently by two reviewers at item level, with disagreements resolved by consensus; the item-level judgments informed the final classifications but are not reproduced in full in this supplementary document.

Final appraisal summary

Instrument	Category	Final result	Interpretation
ROBIS	Low / High / Unclear	11 / 23 / 4	Final overall distribution
AMSTAR 2	High / Moderate / Low / Critically low	0 / 2 / 3 / 5	10 applicable reviews
Agreement	Percent agreement / Cohen’s kappa	89.5% / 0.78	Before consensus

Supplementary Table S3. Primary-study overlap and corrected covered area

Overall primary-study overlap was moderate (CCA 7.6%). The greatest overlap occurred in the injury and health and performance assessment/testing/classification domains. Domain-specific CCA percentages are not reproduced here because the main manuscript reports the domain pattern qualitatively rather than as separate numeric estimates.

Scope	Result	Interpretation	Status
Overall primary-study overlap	CCA 7.6%	Moderate overlap	Final
Domain pattern	Greatest overlap	Injury and health	Final qualitative finding
Domain pattern	Greatest overlap	Performance assessment/testing/classification	Final qualitative finding

CCA formula: CCA = (N − r) / (r × c − r), where N is the total number of primary-study occurrences, r is the number of reviews, and c is the number of unique primary studies.

Appendix S1. Database search strategies

Search period: initiated 5 May 2026 and completed 30 June 2026.

Protocol timing. The archived protocol is dated 5 May 2026 and specifies 5 May 2026 as the study start date and 30 June 2026 as the planned completion date.

The search strategy was peer reviewed by an experienced information specialist using PRESS principles.

MEDLINE via PubMed

Platform: PubMed | Coverage: Inception to 30 June 2026

Final executed search string: ((Paralympic*[Title/Abstract] OR “Para sport”[Title/Abstract] OR “Para sports”[Title/Abstract] OR parasport*[Title/Abstract] OR “Para athlete”[Title/Abstract] OR “Para athletes”[Title/Abstract] OR “disabled athlete”[Title/Abstract] OR “disabled athletes”[Title/Abstract] OR “athletes with disabilities”[Title/Abstract]) AND (systematic review[Publication Type] OR meta-analysis[Publication Type] OR systematic review[Title/Abstract] OR meta-analy*[Title/Abstract] OR evidence synthesis[Title/Abstract] OR umbrella review[Title/Abstract]))

Embase

Coverage: Inception to 30 June 2026

Final executed search string: (‘paralympic*’:ti,ab,kw OR ‘para sport’:ti,ab,kw OR ‘para sports’:ti,ab,kw OR parasport*:ti,ab,kw OR ‘para athlete’:ti,ab,kw OR ‘para athletes’:ti,ab,kw OR ‘disabled athlete’:ti,ab,kw OR ‘disabled athletes’:ti,ab,kw OR ‘athletes with disabilities’:ti,ab,kw) AND (‘systematic review’/de OR ‘meta analysis’/de OR ‘systematic review’:ti,ab,kw OR meta-analy*:ti,ab,kw OR ‘evidence synthesis’:ti,ab,kw OR ‘umbrella review’:ti,ab,kw)

Scopus

Platform: Elsevier Scopus | Coverage: Inception to 30 June 2026

Final executed search string: TITLE-ABS-KEY ( paralympic* OR “para sport” OR “para sports” OR parasport* OR “para athlete” OR “para athletes” OR “disabled athlete” OR “disabled athletes” OR “athletes with disabilities” ) AND TITLE-ABS-KEY ( “systematic review” OR meta-analy* OR “evidence synthesis” OR “umbrella review” )

Web of Science Core Collection

Platform: Clarivate Web of Science | Coverage: Inception to 30 June 2026

Final executed search string: TS=(Paralympic* OR “para sport” OR “para sports” OR parasport* OR “para athlete” OR “para athletes” OR “disabled athlete” OR “disabled athletes” OR “athletes with disabilities”) AND TS=(“systematic review” OR meta-analy* OR “evidence synthesis” OR “umbrella review”)

SPORTDiscus

Coverage: Inception to 30 June 2026

Final executed search string: (TI (Paralympic* OR “para sport” OR “para sports” OR parasport* OR “para athlete” OR “para athletes” OR “disabled athlete” OR “disabled athletes” OR “athletes with disabilities”) OR AB (Paralympic* OR “para sport” OR “para sports” OR parasport* OR “para athlete” OR “para athletes” OR “disabled athlete” OR “disabled athletes” OR “athletes with disabilities”)) AND (TI (“systematic review” OR meta-analy* OR “evidence synthesis” OR “umbrella review”) OR AB (“systematic review” OR meta-analy* OR “evidence synthesis” OR “umbrella review”))

Cochrane Database of Systematic Reviews

Platform: Cochrane Library | Coverage: Inception to 30 June 2026

Final executed search string: (Paralympic* OR “para sport” OR “para sports” OR parasport* OR “para athlete” OR “para athletes” OR “disabled athlete” OR “disabled athletes” OR “athletes with disabilities”):ti,ab,kw

Across the six database searches, 2,846 records were identified before deduplication.

Search management and deduplication

Reported workflow: records exported to Zotero 7.0; Zotero duplicate detection followed by manual verification of title, authors, year, journal, and DOI.

Final screening counts: 2,846 records identified; 912 duplicates removed; 1,934 records screened.

Appendix S2. Full-text exclusions with reasons

The final full-text exclusion reasons and counts correspond to Figure 1 in the main manuscript and sum to 143 excluded reports.

Exclusion reason	Final n	Status
Not eligible systematic-review design	57	Final
Population not directly relevant or data not separable	36	Final
Topic not directly pertinent to competitive Para sport	27	Final
Ineligible publication status	13	Final
Full text unavailable	5	Final
Duplicate / companion / updated report	5	Final
Total	143	Final

Appendix S3. Reproducibility specifications for secondary analyses

The secondary quantitative re-analyses used study-level numerical data reconstructed from Pinheiro et al. (2021) and Baumgart et al. (2018), without a new primary-study search. The archived reproducibility package contains the reconstructed input datasets, analysis scripts, machine-readable result files, leave-one-out outputs, workbook-level validation checks, and execution logs used to verify the secondary analyses. The specifications below reproduce the input structure and analytic choices reported in the final main manuscript.

Component	Source / input	Final specification
Injury prevalence	Pinheiro et al. (2021)	31 prevalence cohorts; injury events and sample sizes reconstructed from the included review.
Injury incidence	Pinheiro et al. (2021)	21 incidence cohorts; reported rates, confidence intervals, and injury counts reconstructed from the included review.
VO₂peak	Baumgart et al. (2018), official supplement	88 absolute and 67 body-mass-normalized rows; sport labels harmonized and sports analysed separately.
Non-independent rows	Multiple rows from a publication	Publication-level aggregation within each sport and outcome scale using inverse-variance weighting before random-effects pooling.
Primary injury models	Study-level reconstructed data	REML with modified Hartung-Knapp confidence intervals; logit prevalence with 0.5 continuity correction when required; log-rate incidence; prediction intervals used t with k-2 df.
VO₂peak / software	Study-level means, SDs, and n	Sampling variance SE²=SD²/n; k=1 descriptive and k=2 interpreted cautiously. R 4.5.1; metafor 4.8-0; meta 8.2-1; dplyr 1.1.4; ggplot2 3.5.2.

Reproducibility and validation. The archived computational package includes separate study-level CSV files for 31 injury-prevalence cohorts and 21 injury-incidence cohorts, together with 88 absolute and 67 body-mass-normalized VO₂peak rows. It also includes leave-one-out results, a complete machine-readable results file, the official Baumgart et al. supplementary workbook used as the VO₂peak source, executable analysis scripts, workbook inspection outputs, formula-error checks, and analysis execution logs. Replication analyses were used as data-integrity checks against the source reviews; the secondary analyses were not treated as updated systematic reviews of primary studies.

Supplementary figures

No supplementary figures are included; all figures cited in the manuscript are presented in the main text.