This article focuses on identifying how health care providers can support a person with spinal cord injury to pursue and maintain involvement in adaptive sports. Benefits and barriers of sport participation, equipment considerations, and recommendations on how to determine sport appropriateness for a person with spinal cord injury will be provided. The authors emphasize through appropriate medical management and consideration of level of disability, functional performance, psychological readiness, and individual preference, a health care provider can play a valuable role in connecting individuals with spinal cord injury to adaptive sports and recreation.
Key points
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Adaptive sports for individuals with spinal cord injury can improve physical health and functioning, psychological well-being, peer connections, overall quality of life, and even lead to employment opportunities.
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Common barriers individuals with spinal cord injury who wish to participate in adaptive sports face include limited access to adaptive sports options and overall accessibility issues, lack of financial resources, and problems with transportation.
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Health care professionals referring an individual with spinal cord injury to adaptive sports should consider the level of disability, functional performance, psychological readiness, and an individual’s personal preferences when assessing eligibility for participation.
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Comprehensive health care, such as obtaining baseline medical status, conducting consistent monitoring of cardiovascular and autonomic function before and throughout sport engagement, and completing diagnostic tests to determine any needed activity parameters, supports successful integration and continued participation in adaptive sports and recreation.
Introduction
There are multiple factors that contribute to the ability of individuals with spinal cord injury (SCI) to thrive after sustaining a life-changing injury. After discharge from rehabilitation, individuals with SCI face many challenges upon returning to the home and community, such as learning to live with loss in function and identity, adjusting to changes in mobility, experiencing decreased self-efficacy, and feeling restricted by accessibility limitations that did not exist preinjury. Life skills training required for successful reintegration in the home and community that were once taught over 90 day rehabilitation stays in the 1970s now occur over a 30 day period in 2021. Due to this shorter duration in rehabilitation postinjury, the focus of training is likely limited to performance in activities of daily living and basic mobility as well as the psychosocial adjustment to injury. As a result, motivating patients with SCI to consider participating in health-promoting activities such as sports and recreation is deferred.
However, evidence suggests introducing people with SCI to sports and recreation earlier in the recovery process, coupled with health care provider support, is key. Adaptive sports offer opportunities for improvement in physical health and functioning, quality of life (QOL), psychological well-being, peer connections, and even employment opportunities. This correlates with the shift seen in the International Classification of Functioning (ICF), Disability and Health, which focuses in health care on bio-psycho-social functioning, disability, and health, to include participation. As defined in the ICF, participation refers to engagement in one’s life, including community involvement such as sports and recreation.
The concept of adaptive sports being incorporated into the SCI rehabilitation process began in 1948, thanks to the pioneering efforts of Sir Ludwig Guttman, the creator of the Stoke Mandeville Games, which later became the Paralympic Games. He not only pioneered sports activity for patients with SCI but also was responsible for sports becoming an integrated part of the rehabilitation course regardless of injury level or type. In 1960, the first Paralympic Games took place in Rome, Italy, with 400 athletes from 23 countries. Today, the Paralympic Games, both summer and winter, continue to be held in the same city as the Olympic Games 2 weeks after the closing ceremonies for the Olympic Games. The Paralympic Games are a major worldwide sporting event and the second largest global sporting event promoting the benefits of adaptive sports and recreation for individuals with physical limitations across the world.
Currently, the development of sports and recreation for people with SCI continues to reach new landmarks with changes in public and university policies promoting inclusion and equality in sports. This involves providing access at all levels of competition, with competitive scholarship teams, club sports, and intramural leagues. The promotion of the Paralympic Games and policy changes emphasizing inclusion and equality within university and collegiate programs have prompted increased interest in local, community-based opportunities for adaptive sports and recreation.
This article focuses on identifying how health care providers can support a person with SCI to pursue and maintain involvement in adaptive sports. First, insight will be given by reviewing the benefits and barriers of sport participation, followed by an overview of equipment considerations. Next, recommendations will be offered on how to determine sport appropriateness for a person with SCI. Resources will be provided, including specific details on the different adaptive sports available to people with SCI.
Adaptive sports participation: considerations, benefits, and barriers
People with SCI can have difficulty adopting a physically active lifestyle due to the psychological adjustment following injury, unawareness of how to engage in physical activity postinjury, and being limited in community exercise options. As a result, it is unsurprising that approximately 50% of people with SCI do not participate in regular exercise and are 1.5 times more likely to be sedentary than the general population. This leads to secondary conditions such as deconditioning and loss of muscle mass, obesity, cardiovascular and metabolic diseases, musculoskeletal conditions, wounds, depression, substance abuse, and social isolation. Participation in physical activity can be a preventive strategy in reducing the risk associated with these secondary conditions. As a result, QOL and overall life satisfaction for individuals with a chronic disability can improve through the positive impact of physical activity on health and well-being.
Involvement in adaptive sports for people with SCI has additional benefits on QOL measures, such as improving self-esteem and self-efficacy, providing a sense of belonging to a group, and maintaining an athlete’s identity. , Ali and Rider conducted semistructured interviews of SCI quad rugby athletes in the United States and found important benefits to sport participation included being introduced to the sport early on by health care providers while in rehabilitation, having peer mentoring during rehabilitation, and having a supportive family. Common barriers to the ability of people with SCI to participate in adaptive sports include the financial burden of sports involvement, limited resources (ie, facilities and training/staff), and accessibility issues. Benefits and barriers to participation in adaptive sports for people with SCI are outlined in Table 1 .
Benefits | Barriers |
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|
|
Essential to the successful integration into adaptive sports is the need for health care providers to acknowledge the positive impact of adaptive sports on people with SCI and be able to provide appropriate medical management. Rayes and colleagues suggested health care providers who refer people with SCI to adaptive sports may benefit from having combined expertise in both disability medicine and sports medicine. Being able to take into consideration an athlete’s baseline medical status, patterns of injury associated with specific adaptive sports, and sport-specific requirements to include equipment needs are important for successful introduction and participation in adaptive sports.
It is important for medical providers to appreciate how physical activity dosage guidelines for able-bodied individuals contain activity intensity and duration recommendations that are difficult for people with disabilities to achieve safely, particularly in cases when a person with SCI is attempting to transition from a sedentary lifestyle to sports participation. Martin and colleagues noted greater health benefits occurred when sedentary people with chronic disability initiated participation in physical activity in small increments with light intensity. Box 1 contains suggestions for health care providers in the management of people with SCI who are interested in participating in adaptive sports.
Prior to Sports Referral
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Screen client for conditions that require further evaluation and/or treatment
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Determine any precautions or monitoring needs
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Identify modifications to avoid injury
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Recommended diagnostic tests
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Exercise stress test to determine peak heart rate and oxygen consumption
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Bone mineral density testing to determine fracture risk and threshold
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Pulmonary function test to identify ventilatory parameters
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Routine blood tests
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Additional points
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Conduct cardiovascular and autonomic function assessments prior to and throughout sports engagement
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Modify concussion assessment to reflect baseline cognitive/neurologic function associated with a client’s specific disability
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Note nutritional requirements for adaptive sports athletes with SCI are different that those of able-bodied counterparts
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Appreciate that knowledge on the impact of longitudinal training and/or the ability to track sports performance in adaptive sports athletes with SCI is lacking
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Equipment
Adaptive and wheelchair sports equipment can be highly specialized and technical. This equipment has a unique function, unlike the typical “day chair” used by people with SCI. For example, a wheelchair rugby sports chair contains bumpers and reinforced frames to accommodate the high impact associated with this sport. Adding to the uniqueness in design and function of adaptive sports wheelchairs, much of this equipment’s innovation and advancement has been driven by its users. For example, Marilyn Hamilton, cofounder of Motion Designs and a wheelchair tennis athlete, sought to design a wheelchair that would be both lightweight and responsive for individuals with disabilities who desired to participate in sports. Marilyn, a former hang-glider, understood the benefits of aluminum on performance and efficiency and introduced aluminum as a new, lightweight material to wheelchair design. The invention of sports-specific wheelchair models soon followed, incorporating materials such as titanium and carbon fiber to optimize performance while removing unnecessary design aspects to minimize weight. , In addition to the evolution of materials, athlete-driven innovations such as the ergo seat, integral antitip, custom side guards, ratchet straps, and high-pressure tires contributed to the improvement in the modern day sports chair both in safety and performance. ,
Sports Wheelchair Design
Wheelchair sports equipment is highly specialized to meet the needs of the individual athlete based on the athlete’s chosen sport and sport-specific classification, when applicable. However, there are principles of design that are considered to be universal across sports. These principles include optimizing the fit of the athlete–wheelchair interface along with the sport-specific wheelchair design, minimizing weight while maintaining stiffness, and minimizing rolling resistance. , ,
Therefore, to augment each athlete’s mobility and sport-specific performance, it is essential to evaluate the interface between the athlete and wheelchair. Success depends on physical ability and how much time and resources are put into adjusting, adapting, and refining an athlete’s wheelchair positioning. To ensure an optimal fit, it is important to have a comprehensive understanding of the athlete, including anthropometric data, sport-specific classification, physical and functional impairments, level of physical fitness, and sport-specific ability. , Ultimately, the wheelchair should serve as an extension of the athlete to truly optimize performance and efficiency and maintain comfort and safety during sport performance. ,
Procuring Equipment
Acquiring adaptive sports equipment can be challenging, as not all adaptive sports programs have adequate equipment supplies, and many prospective athletes lack the financial means and awareness of available funding opportunities to support the cost of obtaining sport-specific equipment. Fortunately, the 21st Century Assistive Technology Act exists to increase the funding for and access to “assistive technology” for individuals with disabilities through comprehensive statewide programs. “Assistive technology” includes any piece of equipment intended to improve function or independence with school, work, recreation, or activities of daily living. To find additional resources for assistive technology and adaptive equipment within a local community, a prospective athlete can contact a local Assistance and Training (AT3) Center. In addition, adaptive sports athletes and organizations may find funding opportunities through local and national grant programs ( Table 2 ).
Organizational Grant Programs | Qualifications |
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Athletes Helping Athletes ( https://www.roadrunnersports.com/content/apply-for-grant ) |
|
Challenged Athletes Foundation ( https://www.challengedathletes.org/grants/ ) |
|
High Fives Foundation ( https://highfivesfoundation.org/grant-application/ ) |
|
IM ABLE Foundation ( https://imablefoundation.org/grant-application/ ) |
|
Kelly Brush Foundation ( https://kellybrushfoundation.org/theactivefund/ ) |
|
Ryan Shazier Fund ( https://ryanshazierfund.org/golden-window/ ) |
|
Score Fund ( https://scorefund.org/applying-for-a-grant/ ) |
|
Triumph Foundation ( https://triumph-foundation.org/outreach/grants-and-equipment/ ) |
|
Determining sport selection
There are many important factors to consider when determining a prospective adaptive sport athlete’s sport selection. A hallmark element of adaptive sports and recreation, compared to standard, able-bodied sport options, is that each adaptive sport has been specifically modified to allow full, active participation for those with disabilities. However, not every disability is the same, so adaptive sports are often categorized by different types of disabilities or impairments. The International Paralympic Committee has established 10 eligible impairments categorized into 3 distinct groups (physical impairments, vision impairment, and intellectual impairment) to assist with determining sport eligibility and performance capacity. Determining adaptive sport appropriateness can be summarized into 4 areas: physical function, participant interest, participant readiness, and accessibility. It is important for practitioners recommending a prospective athlete to a sport or recreation program to understand these areas to identify appropriate sports options that will support successful outcomes.
Functional capacity is important when determining baseline eligibility and potential for successful performance in adaptive sport selection. In formal, competitive settings like the Paralympics, adaptive sports require a “minimum impairment criteria” per sport and subsequent classification of impairments to create an equitable playing field of competition. A person with SCI’s individual level of disability and functional performance are considered not only for initial sport eligibility but also as a part of a classification process that reflects sport-specific physical ability. It is important to ensure that the adaptive sports athlete has the potential to develop the sport-associated skills required for successful participation. Health care providers who refer a client for adaptive sports may consider recreational adaptive sport options instead of competitive sports, depending on the needs and choices of the client.
A factor that may be even greater than physical readineses is the psychological readiness of a person with SCI. Practitioners should be cognizant of how well an individual with SCI is coping with the adjustment and grief following injury prior to recommending adaptive sports and recreation options. Appreciating the readiness of a person with SCIs may provide insight into when it is appropriate to introduce the topic of adaptive sports to a potential participant. One avenue that may help with openness to adaptive sports participation is through lived-experience recommendations from a peer mentor with a similar disability. The value in adjustment to disability by utilizing firsthand experience to educate on the benefits of participation in sports can be very effective in promoting successful sport integration. Overall, determination of participant emotional readiness may be best evaluated by a psychologist within the treatment team, and practitioners should caution from overencouraging adaptive sports participation when a person with SCI is struggling with psychological readiness.
Lastly, practicing a client-centered approach is key in determining whether to recommend an individual with SCI to adaptive sports and recreation sources. It is important to consider the personal interests and preferences of an individual with SCI in order to promote successful integration and continued participation in adaptive sports and recreation. Prospective athletes with preinjury sport interest and a background in sports or athletics are known facilitators for successful participation in adaptive sports. Identifying a prospective athlete’s interest in sports and recreation and specific preferences in sport characteristics, such as competitive versus recreational, individual versus team-based, or sports versus athletics, are also important in promoting successful integration into adaptive sports and recreation.
Involvement in standard, able-bodied sports, recreation, and fitness programs can be limited for those with disabilities due to multiple barriers, as featured in Table 1 . Understanding these barriers may change a practitioner’s recommendations on the involvement of a person with SCI in adaptive sports. For example, suppose a person with SCI lives in a rural community lacking adaptive sports programs with team-based options. In that case, this person may benefit from participating in an individual-based sport. Educating people with SCI on overcoming barriers and utilizing adaptive sports and recreation resources can provide a basis for successful selection and integration into an adaptive sport. Determining a successful adaptive sports match can benefit from the support of an interdisciplinary team, including but not limited to physicians, psychologists, physical and occupational therapists, and recreational therapists.
Summary
Health care providers are a valuable link in connecting people with SCI to adaptive sports by providing appropriate medical screening and monitoring, understanding adaptive sport-specific physical ability requirements, referring people with SCI to sport-specific connections, appreciating the benefits and barriers to participating in adaptive sports, and being a member of an interdisciplinary team. Table 3 includes the most common sports and resources available for individuals with SCI. Each state or region may have additional resources. Table 4 contains nationally based organizations that provide additional sports resources.
Sport | What Is It? | Who Can Participate? | Online Resource |
---|---|---|---|
Archery |
|
| https://www.paralympic.org/archery https://www.worldarchery.sport/ https://moveunitedsport.org/sport/archery/ |
Badminton |
|
| https://moveunitedsport.org/sport/badminton/ https://www.paralympic.org/badminton https://corporate.bwfbadminton.com/ |
Basketball |
|
| https://www.nwba.org/ https://www.paralympic.org/wheelchair-basketball https://turnstone.org/sports https://pva.org/adaptive-sports/ |
Billiards |
|
| https://www.nchpad.org/Directories/Organizations/2085/ https://poolplayers.com/showdown-series/wheelchair/ https://pva.org/adaptive-sports/billiards/ https://www.cannonaid.com/ |
Boccia/bocce |
|
| https://turnstone.org/sports https://pva.org/adaptive-sports/ https://www.worldboccia.com/ |
Bowling |
|
| https://awba.org/ |
Canoeing/kayaking |
|
| http://www.uscanoe.com/adaptive-paddling https://moveunitedsport.org/sport/canoeing/ https://americancanoe.org/ https://www.canoeicf.com/disciplines/paracanoe |
Curling |
|
| https://moveunitedsport.org/sport/curling/ https://www.usacurling.org/ https://worldcurling.org/ |
Dance |
|
| https://www.paralympic.org/dance-sport/about |
|
|
| https://uspea.org/ https://www.fei.org/ https://www.paralympic.org/equestrian https://pathintl.org/ https://moveunitedsport.org/sport/equestrian-horseback-riding/ |
Fencing |
|
| https://www.iwfencing.com/ https://www.paralympic.org/wheelchair-fencing https://moveunitedsport.org/sport/fencing/ https://worldabilitysport.org/sports/international-federation/wheelchair-fencing/ |
Fishing/boating |
|
| https://moveunitedsport.org/sport/fishing/ https://projecthealingwaters.org/ https://fhnbinc.org/ https://pva.org/adaptive-sports/bass-tournament-series/ |
Floorball |
|
| https://powerchairhockey.org/ |
Football |
|
| https://moveunitedsport.org/usa-wheelchair-football-league/ |
Golf |
|
| http://www.adaptivegolf.org/ https://turnstone.org/sports https://moveunitedsport.org/sport/golf/ https://www.usaga.org/ |
Handcycling Off roading |
|
| https://usadaptive.net/adaptive-cycling/ https://moveunitedsport.org/sport/cycling/ https://adaptivesportsnw.org/sports/cycling/ |
Lacrosse |
|
| https://www.wheelchairlacrosse.com/ www.usalacrosse.com |
|
|
| https://adaptivemartialarts.org/about-us https://www.fightcoop.com/adaptive-martial-arts-techniques-for-people-with-disabilities/ https://usadaptive.net/adaptive-martial-arts/ www.adaptivemartialarts.org . |
Pickleball |
|
| https://usapickleball.org/ |
Powerlifting |
|
| https://moveunitedsport.org/sport/powerlifting/ https://www.paralympic.org/powerlifting |
Power soccer |
|
| https://www.powersoccerusa.org/ https://turnstone.org/sports https://moveunitedsport.org/sport/soccer-power-soccer/ |
Racing |
|
| https://livingspinal.com/active-mobility/wheelchair-sports/wheelchair-racing https://www.wheelpower.org.uk/sports/wheelchair-racing/ https://kellybrushfoundation.org/activeproject/racing/ |
Rock climbing |
|
| www.climbroca.com/adaptiveclimbing https://www.commonclimber.com/adaptive-climbing.html |
Rowing |
|
| https://worldrowing.com/ https://usrowing.org/sports/2019/9/19/us-adaptive-programs.aspx?id=961 |
Rugby |
|
| https://www.uswra.org/ https://moveunitedsport.org/sports/wheelchairrugby https://turnstone.org/sports https://pva.org/adaptive-sports/ |
Sailing |
|
| https://www.sailing.org/our-sport/para/ https://www.ussailing.org/education/adult/adaptive-sailing/ https://www.ussailing.org/ |
Scuba |
|
| www.adaptivesportsfund.org/adaptive-scuba-diving https://hsascuba.com/ https://www.iahd.org/en/ |
Sled hockey |
|
| https://www.usahockey.com/disabledhockey https://turnstone.org/sports https://moveunitedsport.org/sport/sled-hockey/ |
|
|
| https://moveunitedsport.org/sport/alpine-downhill-skiing/ https://www.paralympic.org/alpine-skiing https://www.disabled-world.com/sports/snow/ https://www.paralympic.org/snowboard |
Softball |
|
| www.wheelchairsoftball.org |
Surfing |
|
| https://www.sports.org.au/adaptive-surfing https://adaptivesurfproject.com/ https://moveunitedsport.org/sport/surfing/ |
Swimming |
|
| https://usadaptive.net/adaptive-swimming https://www.paralympic.org/swimming https://www.usaswimming.org/ |
Table tennis |
|
| https://www.paralympic.org/table-tennis https://moveunitedsport.org/sport/table-tennis/ |
Target shooting Para shooting |
|
| https://www.paralympic.org/shooting https://moveunitedsport.org/sport/shooting/ https://shootata.com/ |
Tennis |
|
| https://turnstone.org/sports ; https://pva.org/adaptive-sports/ https://moveunitedsport.org/sport/tennis-wheelchair-tennis/ https://www.paralympic.org/wheelchair-tennis |
Track and field |
|
| https://dasasports.org/sports-and-fitness/competitive-teams/track-and-field ; https://adaptivesportsnw.org/sports/track-field https://moveunitedsport.org/sport/track-and-field/ |
Triathlon |
|
| https://www.paralympic.org/triathlon https://triathlon.org/paratriathlon |
Water skiing |
|
| https://www.usaadaptivewaterski.org/ https://learnwatersports.com/adaptive-waterskiing/ https://moveunitedsport.org/sport/water-skiing/ |
Yoga |
|
| https://www.nchpad.org/295/1834/Yoga https://wecapable.com/wheelchair-exercises-chair-yoga-poses/ |

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