Adaptive sports medicine is an area of medical practice that comprises knowledge in the fundamentals of both Sports Medicine and Physical Medicine & Rehabilitation. There are elements that are specific to the diagnoses of adaptive athletes, which impact engagement and participation in physical activity and sports. A review of current literature was performed to explore and discuss the prevalence and efficacy of strategies incorporating adaptive sports and adaptive sports medicine in the curricula across a variety of professional disciplines.
Key points
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Medical education in adaptive sports is inadequate across most professions including physician, therapist, kinesiologist, trainer, coach, and physical educator.
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Adaptive sports and the adaptive/Para athlete are only suggested or recommended topics for inclusion in teaching curricula, contributing to inconsistency and gaps in education.
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Different strategies can be incorporated into adaptive sports medicine curricula including certifications, experiential learning, high-quality educational materials, networking and mentorship, and collaborating with athletes and sports organizations.
Abbreviations
| ACGME | Accreditation Council for Graduate Medical Education |
| ECOSEP | European College of Sports and Exercise Physicians |
| NGB | National Governing Boards |
| NPC | National Paralympic Committee |
| PM&R | Physical Medicine & Rehabilitation |
| PPEs | preparticipation physical examinations |
| PSL | Paralympic Skill Lab |
| SEM | Sports and Exercise Medicine |
| USOPC | United States Olympic Paralympic Committee |
Introduction
Adaptive sports medicine is an area of medicine that comprises knowledge in the fundamentals of both Sports Medicine and Physical Medicine & Rehabilitation (PM&R). While the need for this discipline precedes its distinct origin, one impetus to better understand the needs of soldiers with disability can be traced back to World War II when advancements in medicine and technology led to improved survival rates from trauma and spinal cord injuries. This confluence led to the founding of PM&R as a field of medicine and to physical activity and sport as a means of pursuing wellness and restoring self-identity. Pivotal moments that galvanized this path include the first official wheelchair basketball contest on November 25, 1946 through the collaboration of Robert D. Rynearson, a physical education teacher, and the Birmingham Veterans Affairs Hospital and the inaugural Stoke Mandeville Games (predecessor of the Paralympics) on July 29, 1948 from the vision of Dr Ludwig Guttmann, a neurosurgeon. ,
While this core aspect of PM&R has persisted and gradually grown over time, the roles and purpose of professionals working with adaptive and Para athletes have continued to evolve but lack a clear educational pathway. The concept and need to prepare professionals to meet this demand has been described in the literature of physical education and kinesiology since the 1950s. , Guttmann published Textbook of Sport for the Disabled in 1976, which did not provide sufficient medical context for sports physicians. In the 1980s, medical publications echoed these sentiments as they described a need for education of health care professionals taking care of athletes with disabilities. Despite this recognition among the communities directly involved in the care, education, and well-being of athletes with adaptive needs, it was not until 2017 when De Luigi published the first textbook dedicated to the medical considerations of Para athletes and sport.
The field of adaptive sports medicine can provide understanding of a wide range of medical conditions that affect the adaptive athlete and how those conditions affect engagement and participation in physical activity and sports. This is an area of medical education often seen as supplemental but is vital to medical professionals who support or serve the adaptive and Para athletes.
Methods
Search Strategy and Information Sources
This article was conducted according to the JBI Manual for Evidence Synthesis . Medline via Ovid, ERIC via Proquest, Scopus via Elsevier, Embase via Elsevier, and Web of Science (citation indexes: Science Citation Index Expanded, Social Sciences Citation Index, and Emerging Sources Citation Index) were searched by a health sciences librarian on December 20, 2024, and January 24, 2025, to identify literature on adaptive sports education for health care professions students. No date or language filters were applied.
Study Selection
Citations were uploaded in Covidence, a web-based collaboration software platform that streamlines the production of systematic and other literature reviews, for screening and data extraction. Titles and abstracts were reviewed by a single author to exclude irrelevant abstracts using predetermined inclusion and exclusion criteria. The following 5 eligibility criteria were selected by the 2 authors: (1) focus on curricula or education models for physicians, allied health professions, or associated professions; (2) relate to adaptive physical activity, exercise, or sport; (3) published in the English language; (4) published in an online or paper format; and (5) accessible through one of the libraries at the Department of Veterans Affairs, University of Michigan, or University of Minnesota. At least one author reviewed each full text article to identify relevant articles for data extraction.
Results
A total of 1095 abstracts were retrieved through the electronic searches and uploaded in Covidence. The Covidence software identified 579 duplicates, and the author team manually removed 1 additional duplicate. After screening 515 abstracts, 90 articles were advanced to full text review. From these, 36 articles met the criteria for inclusion in this article. A flow diagram of the selection process is shown in Fig. 1 . Of the 36 articles, 10 related to physician education, 22 to allied health professions education, and 9 to associated professions education. Note that some articles were counted more than once as they reference multiple professions.
Flow diagram of study selection. Diagram generated with PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses.
Discussion
In the scope of this article, adaptive sports medicine education is limited. Conversely, the topic touches a wide variety of disciplines. It also covers teaching general knowledge about disability as well as pedagogical considerations, specific strategies, and teaching tools for the student/learner. Themes frequently stated in the literature include the need for specialized education, increased hands-on experience with individuals with disability, collaboration across different disciplines, and connection with local adaptive sports programs and organizations.
Physician Education
According to current Accreditation Council for Graduate Medical Education (ACGME) education requirements, medical conditioning and reconditioning and fitness are addressed in PM&R residency but not specifically the continuum of adaptive sports and Para sports. Also outlined by ACGME, there is no core requirement for education in adaptive sports medicine incorporation into Sports Medicine Fellowship training. In a survey of Sports Medicine fellowship graduates, work with disabled athletes was rated among the lowest in areas of fellowship training and had a much higher rate of “not available” scores. The data did not present why experience with disabled athletes was so limited in most fellowships. Olufade and colleagues describe elements, which should be covered within PM&R residency, to develop expertise in musculoskeletal and Sports Medicine. They recommend PM&R residents require additional training in sideline sporting event coverage, mass event participation, preparticipation physical examinations (PPEs), medical management of athletes, diagnostic and procedural ultrasound, and exposure to orthobiologics. They also specifically note to include physiatric areas of Sports Medicine, providing examples such as spinal cord injury and the disabled athlete, integrative sports medicine, prosthetics and orthotics in sport, and peripheral nerve pathology.
The challenges that PM&R residents and Sports Medicine fellows face are not unique to their pathway to specialization. They are complex issues that can be traced, in part, to undergraduate medical training. Many medical schools begin their first-year students’ curriculum with anatomy. This early introduction helps set the stage for systems-based learning and can facilitate students’ conceptualization of the body’s form and function. This is particularly helpful in the realm of rheumatologic and musculoskeletal medicine whose associated conditions are experienced by an estimated 2 billion individuals and account for the second leading cause of living with disability worldwide. Given its significance and relationship to understanding disability and the care of those impacted, Harkins and colleagues explored the quality of musculoskeletal science education for undergraduate medical students across the globe. Eleven studies met their eligibility criteria and represented medical schools in Europe, Africa, Asia, North America, and South America. Their review found that the mean self-rated clinical confidence of medical students in one study was “low,” 37% of medical students in another study reported their associated curricula as “poor,” and only 40% of medical students reported self-perceived competence in musculoskeletal medicine a separate study. As such, they determined that overall musculoskeletal science education received at medical schools is inadequate. They subsequently reviewed strategies to combat this deficiency. Technology-assisted learning is well accepted (97%) by medical students and implementing certain components like substituting podcasts in place of textbooks led to higher knowledge acquisition but was equivalent to traditional lectures. While an exciting concept, employing virtual reality had mixed results with no statistically significant difference to physical model simulations in one study. However, the time required to achieve the same level of mastery was significantly reduced between 3 dimensional anatomy simulation and standard cadaver learning. Just as in sports, teamwork via near and assisted peer learning was beneficial and resulted in improved performance on written and practical-based examinations, clinical reasoning, clinical confidence, and competence. When considering the broader medical community’s comfort level with the assessment and treatment of the general population’s musculoskeletal pathology, the need for increased exposure to caring for individuals with disability is of paramount importance as it is more challenging given the variances in bone and joint alignment as well as altered muscle anatomy, which can have a torsional component in some conditions.
One model for additional physician training described in the literature is the European College of Sports and Exercise Physicians (ECOSEP) Sports and Exercise Medicine (SEM) Traveling Fellowship. Selecting a variety of settings throughout the fellowship allows for experience in high-level Sports Medicine and performance enhancement strategies, sports event planning, periodic fitness level assessments, sports injury management, rehabilitation, psychological interventions, and acclimatization for varying climate conditions. Because specific settings could be selected, this model included exposure in working with paralympic athletes. Having some variability in what settings are covered can expand exposure to adaptive sports medicine.
An event-based model is described in the literature, impacting health care professional education with respect to athletes with intellectual disabilities is the Special Olympics Healthy Athletes program. A component of the program is MedFest, which has screening protocols based on the standard PPE protocols but have been tailored to include areas of concern that are more prevalent in the Special Olympics athlete population, such as spinal cord compression, cardiac defects, seizure disorders, and behavioral issues. Holder and colleagues note, in 2007, the Special Olympics and the American Academy of Developmental Medicine and Dentistry performed a survey of medical schools and residency programs in the United States, and at that time, 81% of graduating medical students had received no training with respect to caring for adults with intellectual disabilities. The Special Olympics Healthy Athletes affords physicians and other health care providers a unique opportunity to come into contact with a large number of people with intellectual disabilities. This model, like other event-based learning experiences, can provide valuable experiential learning that clinicians will be able to take what they learn and apply to their own medical practice.
The medical learning around the Special Olympics World Games (SOWG) was described by Rubin and colleagues with a detailed outline of curriculum and the road map used to include residents in event-based education. A symposium was created with presentations on sideline emergencies, care of sideline traumatic injuries, medical conditions common in the Special Olympics athlete, and communicating with those with intellectual disabilities with over 450 physician volunteers who were participating in the games. Electronic learning modules were set up for volunteers unable to make the live symposium. They point out that preparing for large-scale participation by resident physicians required attention to institutional sponsorship, credentialing, education, and scheduling. Training requirements also included review of common medical conditions and sideline medical care for the Special Olympics athletes. Each of the residency physicians completed the online training modules and participated in the sports medicine training for SOWG at the residency program. They also received training in advance for how to electronically document medical encounters in real time at the event. At SOWG, the physicians were provided with standardized medical kits to use on site and instructed on their contents. Prior to the Games, periodic training included planning communications and interacting with local Special Olympics athletes. A tactical medical course was provided on the use of tourniquets, chest seals, and bandages and to familiarize them with emergency response from law enforcement and fire rescue in case of a serious mass casualty event. This is one example of a comprehensive model, which could be applied to other large games and multisport events.
Allied Health Professions Education
Therapist education (physical therapy, occupational therapy, and recreational therapy)
Like all sports, adaptive sports and activity require a team of individuals to adequately prepare athletes and promote performance. Individuals with disabilities benefit from tailored instruction that address their unique situation, whether it be physical, cognitive, or a combination of impairments. Allied health professionals are integral members of the multidisciplinary team that can collaborate to provide holistic and athlete-centered care. However, professionals in such disciplines often need to seek education beyond their standard training to be fully successful in this endeavor. Appropriate training and implementation seem to be essential to change current practice.
A study focused on intellectual disability notes that current training does not appear to provide allied health professionals with the skill set and clinical experiences to appropriately support people with intellectual disabilities to be active. In Australia, the amount of teaching is inconsistent with many programs having little to no content on intellectual disabilities. With no mandatory or minimal requirements to provide specific educational content on intellectual disabilities, university trained health professionals can receive as little as 2.6 hours within all their training, which equates to less than 1% of the degree.
One study surveyed pediatric rehabilitation professionals and coaches who traditionally assume roles of physical activity promotion (ie, physical education, coaching youth recreation, and sport) that support physical literacy and reported having variable knowledge and training about physical literacy. The study points out that physical literacy is a building block to physical activity participation but there is a lack of knowledge transfer and application of physical literacy for children with physical disabilities in practice.
Recreation therapy centers on returning purpose, fulfillment, and integration within one’s community to its participants. To achieve this, exposure to working with individuals with disability and assisting them with engagement in physical activity is central to their training. Furthermore, recreation therapists can pursue subspecialization in adaptive sports and recreation. Despite the standards and core tenets of this profession, this literature search did not identify any articles that discussed their training or exposure to Para athletes and sport.
Athletic trainer education
While athletic training is a key aspect of establishing and maintaining safe environments for participation and competition in sport, no articles or studies were identified in this literature search that discussed their training or exposure to Para athletes and sport.
Kinesiology and physical educator education
Kinesiology and adapted physical education have a shared origin as they both developed from the underpinnings of exercise and physical activity as a medical intervention. , Their historical approach to treatment focused on “corrective” interventions as a means of achieving or restoring a neurotypical appearance and function. Overtime, advocacy from organizations like the American Alliance for Health, Physical Education and Recreation who published the Guiding Principles for Adapted Physical Education in 1952, and legislature like the Rehabilitation Act of 1973 & Education of All Handicapped Children Act of 1975 (Individuals with Disabilities Education Act) have led to pedagogical change to adapted physical education and activity. ,,
In 1954, Allport introduced contact theory, which has served as the foundation upon which many in the field of kinesiology have built their active learning education models. It centers on the enhancement of learning through experiential learning via purposeful interpersonal contact between the trainees and individuals with disabilities as the belief was this would reduce misperceptions and prejudice leading to improved positive attitudes toward this special patient population. ,,,, The validity of this theory has been reviewed many times over the years with fairly reliable outcomes as some studies did not reach statistical significance thresholds. The variability in outcomes was attributed to curricular design (ie, shorter term courses) with service-learning being the preferred mode of delivery as it has been associated with positive self-efficacy of working with people with disabilities. ,,
In 2019, McKay investigated the influence of a service-learning component to the curriculum of an undergraduate kinesiology-based general education course, lifetime wellness. The study had a final sample size of 192 college students of which 91 were in the control arm receiving traditional instruction and 101 were in the experimental arm participating in a Paralympic Skill Lab (PSL). The PSL experience applied a modified version of the Paralympic School Day curriculum and lasted only one class period (50–75 minutes). After controlling for confounding factors, the result of the study indicates a significant positive change on the attitude levels of the treatment group toward the inclusion of people with disabilities in physical activity, recreation, and sport to achieve lifetime fitness.
In 2022, McKay and colleagues followed upon with a qualitative study to explore the impact of the PSL experience from the perspective of the student. A total of 77 undergraduate students completed a 10 item questionnaire after the lab. Their responses were coded and categorized as Emotional, Gained New Knowledge, Changed Attitude, Disabled People are Able, Respect for People with Disabilities, and Inclusion and Disability Sport are Important. Key among the study results were the positive emotive responses suggesting the power of the PSL’s influence resides in the emotional engagement it draws from its participants.
Hauck and Felzer-Kim followed a similar line of investigation as they explored the effect of inclusion of adapted physical activity in the curriculum of an undergraduate kinesiology course in comparison to a similar upper level course without this component. The primary objectives of this study were to understand how the intervention would impact the knowledge and perceptions of the trainees regarding physical activity and autism spectrum disorder. After analyzing the survey data of the 400 participants (251 intervention arm, 149 control), they concluded that results favor adaptive physical activity education in conjunction with service learning with children with disabilities improves self-efficacy, perspectives, and knowledge of physical activity and motor concerns in children with autism spectrum disorder.
In areas like Ontario, Canada, where 44% of the county’s children and youth with disabilities reside of which 17% received special education programming and/or services, the impetus to properly prepare teachers and have adequate comprehensive training resources led to the development of Steps to Inclusion . This is an open access online education resource created by a collective of community stakeholders including teachers, parents, coaches, disability organizations, and safety consultants. Tristani and colleagues performed a theoretic content analysis of the resource with respect to behavior change theory and quality participation. They discovered that 85.3% of the theoretically relevant content was aligned with the Theoretical Domains Framework, which they used to assess behavioral determinants associated with behavior change theory, but only 14.7% was coded to the quality participation model. They postulated that addressing the latter by bolstering associated content would improve the teachers ability to conceptualize and develop more robust adaptive physical education programming with higher quality physical activity.
Another Canadian-based effort to promote and evaluate adapted physical education through a similar grassroots efforts of a collaboration among staff and kinesiologists associated with 2 community-based adapted physical activity programs and researchers from 2 universities. They cocreated 9 online training models based on Kolb’s experiential learning theory incorporating concrete experience, reflective observation, abstract conceptualization, and active experimentation. The modules centered on behavior change techniques, motivational interviewing, and physical activity prescription. Subsequently, the 14 participants completed questionnaires that indicated medium-large improvements among multiple domains. Of the respondents, 9 participated in recorded mock client sessions that were reviewed and graded. The 9 of 9 participants demonstrated fair to good with motivational interviewing with 7 of 9 achieving good. Participants estimated spending 32 minutes per module with an average of 285 minutes to complete the entire course. These results suggest that favorable change in competence can be achieved with a relatively small time commitment via participation in course work that can be remotely accessed.
Associated Professions Education
Coach education
Coaches are an essential role for athletics and sports. Those who better understand their athletes’ needs—cognitive, emotional, and physical—and aspirations are better able to tap into their true potential and promote performance or lifelong healthy lifestyles. , However, there is not a clear path for coaches to prepare themselves to achieve this responsibility in relation to Para sport. , Fairhurst and colleagues set out to understand how Paralympic coaches readied themselves to meet the demands of rapidly increasing participation in the Paralympic Games while empirical literature for coaching in adaptive sports has lagged behind. They performed a qualitative study where they interviewed 6 highly successful and experienced Paralympic coaches. Due to the paucity of formal training opportunities, the Paralympic coaches addressed their knowledge and experience gaps through informal education with an emphasis on mentorship. This has resulted in the creation of a coaching community who proactively incorporate aspiring coaches into this network to aid in their career development and the sustainability of the hard-earned lessons of this field.
Personal trainer education
Beattie and colleagues surveyed personal trainers who noted they are most successful when they have the opportunity to work with individuals with disability who have a diverse range of disabilities. They also acknowledged it is important to know “varying expressions” of a particular diagnosis or disability and understand how that diagnosis can have day-to-day fluctuations in ability. This level of knowledge allows the trainer to be more highly individualized in their approach.
Catalysts for Change
Current events like the COVID-19 pandemic directly influence the medical needs of society and consequently the evolution of medical education. This sequence of events happens rapidly in a concurrent manner during the acute phase and then transitions to a gradual integration occurring in tandem and at times in parallel. The formation of the field of PM&R as well as the advancements in rehabilitation and change in mindset regarding physical activity for the injured and disabled veterans following the World Wars in the early twentieth century are prime examples of the former. The latter is well characterized by the challenges of fully integrating adapted physical education programs into schools and standardizing the education and exposure to disability in the curricula of physical educators. A major impetus for change occurred on December 13, 2006, when the United Nations General Assembly adopted the Convention on the Rights of Persons with Disabilities, which included Article 30 which addresses participation in cultural life recreation, leisure, and sport. It states, “With a view to enabling persons with disabilities to participate on an equal basis with others in recreational, leisure and sporting activities, States Parties shall take appropriate measures: (a) To encourage and promote the participation, to the fullest extent possible, of persons with disabilities in mainstream sporting activities at all levels; (b) To ensure that persons with disabilities have an opportunity to organize, develop and participate in disability-specific sporting and recreational activities and, to this end, encourage the provision, on an equal basis with others, of appropriate instruction, training and resources; (c) To ensure that persons with disabilities have access to sporting, recreational and tourism venues; (d) To ensure that children with disabilities have equal access with other children to participation in play, recreation and leisure and sporting activities, including those activities in the school system; (e) To ensure that persons with disabilities have access to services from those involved in the organization of recreational, tourism, leisure and sporting activities.” Development of adaptive sports medicine education is in direct support of what is outlined by the United Nations.
While the immediate and long-term goals of organizations may fluctuate according to the circumstances of today, the manner in which we approach these may be applicable regardless of the moving target. As such, a general framework that can be applied to the curricula design of educational opportunities is displayed in Table 1 along with the interrelationship of its components in Fig. 2 .
Table 1
Adaptive sports medicine education curricula design elements
Courtesy of Dr Alexander Senk, MD.
| Requirement | Required | Elective |
| Formality | Formal | Informal |
| Format |
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| Modality | In-person | Virtual |
Related posts:
Mental Health in Adaptive and Para Athletes
Periodic Health Evaluations in the Adaptive Athlete
Models and Methods Addressing Inclusion and Access to Adaptive Sports
Paralympic Training
Clinical Recommendations for Female Para and Adaptive Athletes
Ultrasound Applications in Adaptive Sports Medicine
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