Environmental factors such as lack of accessibility of the built infrastructure and rough terrain of public spaces play a role in limiting physical activity engagement by people with disabilities. A longitudinal survey of 28 adult wheelchair users evaluated the barriers and facilitators to accessibility of various settings, demonstrating that the most frequent environmental barriers were issues such as lack of ramps, lack of curb cuts, insufficient parking, inaccessible bathrooms, and narrow aisles between exercise equipment [21].

Studies utilizing focus groups of people with disabilities have also revealed additional barriers to exercise such as doorways being too narrow for wheelchairs and a lack of elevators in fitness facilities. Ease of communication with fitness facility staff was also often limited due to the front desk being too high for wheelchair users. Furthermore, fitness facilities often lack adaptive equipment for individuals with physical or sensory impairments, such as upper body cardiovascular exercise equipment [14, 22]. Of note, similar focus groups revealed that environmental facilitators included fitness centers having ample accessible parking spaces, push-button operated doors, nonslip mats in locker rooms, multilevel front desks to accommodate wheelchair users, ramp access to whirlpools and hot tubs, and Velcro straps to help grip exercise equipment. Many people with disabilities also noted the benefits of having family changing rooms to allow dressing/undressing assistance from family or personal care attendants [14].

With regard to outdoor fitness facilities, the vast majority of playgrounds and nature trails often do not accommodate children and youth with disabilities [23]. Additionally, the trails in the majority of parks are frequently rough, uneven, and difficult to navigate for people with mobility-related disabilities. In response, the US Department of Justice, Civil Rights Division, and the US Access Board have developed accessibility requirements reflecting the tenets of the Americans with Disabilities Act (ADA) and the Architectural Barriers Act (ABA). Regarding accessibility of playgrounds, the 2010 ADA Standards for Accessible Design and the ABA Accessibility Standards both outline requirements to optimize accessible play. In certain areas, there has been greater progress with development of specifically designed adaptive playgrounds for children with disabilities. As an example, playgrounds with non-sloped and smooth play surfaces and ample turning space are easier to navigate for children who use wheelchairs [24]. A longitudinal study on the accessibility of 35 playground surfaces, conducted by the National Center on Accessibility in 2008, found that newly constructed playground sites with loose-fill wood fiber surfaces deviated the most from accessible standards (excessive running slope, cross slope, and change in level) within 12 months from installation and also presented the greatest challenge to move across the playground surface in a wheelchair. Of note, this longitudinal survey found that tile and poured-in rubber required less exertion from the standpoint of the wheelchair user. Hybrid surface system, where there is some type of loose-fill base covered by a unitary mat, was felt to be the most durable and cost effective [25].

Personal barriers can also limit engagement in physical activity and sports. Common barriers for children and adults with disabilities are personal illness, limited strength or poor physical condition, lack of will, and lack of motivation [21, 23]. Financial difficulties can also limit sports and exercise participation by people with disabilities as the costs for travel, equipment, and facility fees result in a high economic burden [8, 17, 23]. Lack of insurance coverage for the fees associated with community fitness facilities may also hinder participation. A survey-based study on women with physical disabilities and another on individuals with stroke both found that specific barriers to exercise included the cost of joining a fitness center and not knowing how or where to exercise [8, 26]. Similarly, a systematic review on children with disability noted that fear of exercise, lack of exercise knowledge, negative perceptions of disability, and attracting unwanted attention presented significant barriers [23].

Personal facilitators to engagement in physical activity and sport include good morale, good health, and personal fitness [21]. In a population of youth with disabilities, the desire to be fit and active, having fun, gaining confidence through exercise, possessing the required skills for exercise, as well as having an introduction to integrated play environments were personal facilitators [23]. Likewise, a survey of 76 adult Paralympic athletes found that fun and relaxation (78%), health and physical fitness (61%), and competition and winning (53%) were personal facilitators for initiating sports. Maintenance in sports participation was also influenced by health (76%) and competition (72%) [27]. In a population of individuals with spinal cord injury, preinjury sports participation has been correlated with the earlier initiation of consistent sports participation post-injury as well as longer duration of participation [28]. Findings also emphasized the importance of early education with regard to sports opportunities, such as prior to discharge from formal inpatient rehabilitation.

Many interpersonal and social factors also serve as barriers or facilitators to physical activity and sports participation. In a population of children with disabilities, unsupportive peers, lack of friends to participate with, and negative societal attitudes were notable social barriers to physical activity [23]. This trend was also noted in adults with SCI and wheelchair users, who noted that a perception of feeling patronized and other people’s rudeness were significant barriers [21, 29]. Other barriers for children with disabilities can come from parents, such as their concern for the child’s safety with physical activity or lack of parental knowledge of the available physical activity opportunities [23]. Furthermore, lack of trust in the competence of exercise staff at fitness centers can also serve as a barrier to exercise [26]. Concomitantly, fitness staff may have negative attitudes toward working with people with disability. For example, some fitness staff consider working with children with disabilities more difficult or are fearful of physical harm to children and resultant legal implications [23]. Lack of fitness facilities and limited availability of inclusive exercise and recreation programs were noted barriers in both children and adults with disabilities [23, 27]. Furthermore, there is a notable lack of transition programs from rehabilitation to the community setting for individuals with disability [23].

Conversely, social support, awareness, and education are common themes for facilitators to physical activity and sports in children and adults with disabilities. Awareness of inclusive recreation programs and availability of community-based programs are notable social facilitators for children with a disability. Additional social facilitators include parental or family support, positive encouragement from peers, and increased disability awareness of parents, peers, and staff [23]. Interviews of athletes with SCI also reveal that playing sports with peers provides social support and motivates individuals to achieve greater functional independence [29]. In fact, athletes with SCI often describe how their peers are valuable sources of information for how to get involved and gain skill in sports [28]. It is important to note that the recognition of the numerous barriers and facilitators to physical activity above can help serve as the basis for public health policy.

Numerous public health initiatives have been established in the United States to increase physical activity engagement and help deter the rising rate of obesity and chronic disease due to sedentary lifestyles. In this setting, various strategies have been employed in an attempt to recruit the participation and inclusion of people with disabilities. Generally speaking, public health programs are either (1) mainstream programs targeted toward the general population, yet inclusive of people with disabilities, or (2) specifically targeted to the disability population (Table 30.2). It is commonly accepted that the use of both strategies concurrently is an optimal strategy toward ensuring the maximum involvement of the disability community.