Sport is a cultural phenomenon and an integral part of society. It is highly visible and touches almost everyone as participants, spectators and consumers - DePauw & Gavron (2005).
Sport represents an efficient rehabilitation method for persons with disabilities. Through regular sporting activity persons with disabilities can achieve greater quality of life and improved social inclusion. For this purpose persons with disabilities need to be provided with the possibility of participating in appropriate sport programme, where they can equally participate. Sporting activities need to become a component of rehabilitation of persons with disabilities regardless of the nature or degree of their disability, age and level of physical competence.
Definition of Rehabilitation
The World Health Organisation
The WHO (2011) defined rehabilitation as “a set of measures that assist individuals who experience, or are likely to experience disability, to achieve and maintain optimal functioning in interaction with their environments. Rehabilitation provides disabled people with the tools they need to attain independence and self-determination.”
The European Standards in Adapted Physical Activities
The EUSAPA (2010) stated that “Rehabilitation is concerned with identifying and maximising quality of life and movement potential within the spheres of promotion, prevention, treatment/intervention, habilitation and rehabilitation, encompassing physical, psychological, emotional, and social well-being.”
The United Nations Convention on the Rights of Persons with Disabilities
The UNCRPD (2007) outlined the responsibility of states to provide “appropriate measures, including through peer support, to enable persons with disabilities to attain and maintain their maximum independence, full physical, mental, social and vocational ability, and full inclusion and participation in all aspects of life.”
Definition of Adapted Physical Activity – Play, Game Sport
Sport is defined as “all forms of physical activity which, through casual or organised participation, aim at expressing or improving physical fitness and mental well-being, forming social relationships or obtaining results in competition at all levels.” (European Sports Charter 1992; revised 2001).
Adapted Physical Activity (APA)
APA can be defined as the provision of physical activity services and programmes to persons of all ages with special needs (Hutzler & Sherrill, 2007). APA includes, but is not limited to, physical education, sport, recreation, and rehabilitation of people with disabilities (EUFAPA, 2006, article 5).
According to the International Federation of Adapted Physical Activity (IFAPA), APA means:
- A service-oriented profession
- An academic specialisation or field of study
- A cross disciplinary body of knowledge
- An emerging discipline or subdiscipline
- A philosophy or set of beliefs that guides practices
- An attitude of acceptance that predisposes behaviours
- A dynamic system of interwoven theories and practices
- A process and a product (i.e. programmes in which adaptation occurs)
- An advocacy network for disability rights to physical activity of participants with disability
The benefits of Sports in the Process of Rehabilitation
The history of Sport in Rehabilitation
Although the use of physical activity in rehabilitation can be traced as far back as 3000 B.C. in ancient China (EUSAPA, 2010), the modern evolution of physical activity and sports as a means of rehabilitation is attributed, among others, to the Swedish scholar Per Henrik Ling (1776-1839). Ling established a system of medical gymnastics in the University of Stockholm, Sweden after curing himself from rheumatism and paralysis through practising fencing and gymnastics (Hutzler, 2010).
The inclusion of sport and organised competition in rehabilitation is associated with Sir Ludwig Guttmann, founder of the International Stoke Mandeville Games in 1948, followed by the first Paralympics in 1960 and the Special Olympics in 1968. Since the 1970s there has been a dramatic increase in the number of international organisations/associations serving athletes with disabilities (De Pauw & Gavron, 2005).
The European Standards in Adapted Physical Activities (EUSAPA, 2010) identifies three main areas of benefit of APA for rehabilitation:
- Adapted physical activities during, but also after the rehabilitation phase have a beneficial effect on an individual’s general physical fitness level, their functionality, and performance of activities of daily living. Research suggests that physiotherapy programmes often pay insufficient attention to these domains, therefore implementing adapted physical activities within the rehabilitation programme may result in an enhanced quality and successfulness of rehabilitation, while also reducing the risk of relapse.
- Adapted physical activities have a beneficial effect on the patient’s/client’s psychosocial well-being, reducing isolation and sedentary lifestyle. Adapted physical activities offer opportunities to share experiences and to learn how to accept or come to terms with an impairment, disorder, etc.
- In addition, individuals experience the benefits of physical activity and sports with respect to their physical and mental and psychosocial well-being, enhanced quality of life and the improved execution of activities of daily living.
APA vs Physical Therapy (PT)
Hutzler (2010) highlighted that the differences between physical therapy (PT) and APA suggested by Lorenzen (1961) are still evident today:
- A medical orientation in PT, compared to a pedagogical orientation in APA;
- Intervention goals mostly refer to the impairment in PT compared to the whole person and participation in APA;
- Activity is typically prescribed in PT, compared to self-motivation in APA;
- The participant is passive and active in PT but only active, mostly in group settings, in APA;
- The goal in PT is mostly restricted to specific biological changes, while in APA the goal is promoting activity across the lifespan;
- The intervention is mostly identified as treatment in PT, compared to self-determined action in APA.
The Benefits of Sport and APA in Rehabilitation
As with the general population, physical activity reduces the risk for chronic illnesses and secondary conditions for persons with disabilities (Durstine et al., 2000; Heath & Fentem, 1997). However the benefits of participation in sports and APA reach beyond physical rehabilitation (Parnes and Hashemi, 2007), improving independence and empowerment, increasing social integration and inclusion, and helping to change attitudes among members of the society in general (Burchell, 2006; Capella-McDonnall, 2007; Sherrill, 2004).
APA and sport promotes rehabilitation through social networks between those who share similar life experiences and through teaching how to function with relative autonomy (Lindemann & Cherney, 2008), this happens in both causal recreational activity as well as elite disability sport (Cherney, Lindemann & Hardin, 2015). Social networks can help people negotiate constraints to participation, including lack of knowledge about an activity or lack of motivation to participate (Jackson, Crawford, & Godbey, 1993; Jackson & Scott, 1999). Both children (Seymour, Reid, & Bloom, 2009), and adults with disabilities report developing friendships as one of the benefits of participation in sport and APA (Ashton-Shaeffer, Gibson, Autry, & Hanson, 2001; Lindemann & Cherney, 2008).
Opportunities for Participation
UNCRPD, Article 30
Article 30 addresses equal participation of persons with disabilities in recreational, leisure and sporting activities and states that State Parties shall take appropriate measures:
- To encourage and promote the participation, to the fullest extent possible, of persons with disabilities in mainstream sporting activities at all levels;
- 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;
- To ensure that persons with disabilities have access to sporting, recreational and tourism venues;
- 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;
- To ensure that persons with disabilities have access to services from those involved in the organization of recreational, tourism, leisure and sporting activities (UN, 2006).
APA and the International Classification of Functioning, Disability and Health
APA is strongly associated with an understanding of the interrelationship between the person, the environment and the task (Kiphard 1983; Newell 1986; Reed 1988). In 2007, Hutzler and Sherrill proposed the WHO’s International Classification of Functioning, Disability and Health (ICF: WHO 2001) as a conceptual framework for the planning and implementation of APA.
ICF is a comprehensive classification system designed to capture aspects of human functioning in the context of a health condition. The system consists of a hierarchy of classifications for each of its domains: Body Functions and Structures, Activities and Participation, and Environmental Factors (See figure 3. below) and has been widely accepted among rehabilitation services worldwide (Hutzler, 2010). Codes can be recorded for each classified item within a domain to indicate the extent of ‘problem’ with any of these aspects of functioning. Environmental Factors can be recorded as being either barriers to or facilitators of a person’s functioning (Bufka, 2009).
Helpful resources explaining how to use the ICF are available from the website: http://www.who.int/classifications/icf/en/
Figure 3: ICF example adopted from ‘WHO, How to use the ICF: A practical manual for using the ICF’ (2013).
EUSAPA Functional MAP - Rehabilitation
The EUSAPA (2010) developed functional guidance for the design and implementation of APA in rehabilitation, consisting of four key areas:
A.1. Assess the role and added value of an Adapted Physical Activity programme within the multidisciplinary character of the rehabilitation programme.
A.1.1. Identify the responsibilities of the APA programme as a complementary part of the rehabilitation programme.
A.1.2. Identify the strengths and weaknesses of the currently used rehabilitation and APA programme.
A.1.3. Identify the available and required resources (facilities, equipment) to implement the APA programme.
A.1.4. Develop a structured Adapted Physical Activity programme in collaboration with rehabilitation team.
A.1.5. Identify the short and long term aims of the Adapted Physical Activity programme.
A.2. Assess the (dis)abilities, risk factors, needs and potential of the patient / client.
A.2.1. Understand the condition of the patients / clients and its consequences in terms of functional (dis)abilities, health conditions, etc...
A.2.2. Understand clinical investigation data (e.g. X-rays, gait analyses, cardiorespiratory tests) and the conclusions and recommendations of rehabilitation specialists.
A.2.3. Assess the patient’s / client’s current and potential level of functioning.
A.2.4. Understand the patient’s / client’s response to physical activity; identify and remediate potential contraindications, health risks and risk factors.
B. Education & Information
B.1. Educate patients / clients about their (dis)abilities and potential through physical activity.
B.1.1. Educate the patient / client about his/her functional (dis)abilities, response to exercise, potential health risks, risk factors and contraindications with regards to physical activity.
B.1.2. Educate the patient / client about the recognition and remediation of symptoms that potentially lead to health risks, injuries, etc...
B.1.3. Educate patients / clients about the APA programme and its benefits during rehabilitation.
B.2. Provide the appropriate information to guarantee a continuation of an active lifestyle post rehabilitation.
B.2.1. Inform the patient / client about community based physical activity programmes, and the short and long term benefits of physical activity.
B.2.2. Provide a database with information regarding companies and community based organisations to ensure a continuation of an active life style post rehabilitation.
B.2.3. Provide information regarding legislation about possible benefits from national, regional and local governing bodies with respect to physical activity and sports post rehabilitation.
C.1. Implement an individualised Adapted Physical Activity programme complementary to the other disciplines within the rehabilitation programme.
C.1.1. Develop a structured and individualised APA programme in collaboration with the multidisciplinary team.
C.1.2. Facilitate and optimise participation through adaptation of the instructions, encouragements, rules and settings when appropriate.
C.1.3. Initiate community based physical activity.
D. Assessment & Evaluation
D.1. Evaluate the effects of the Adapted Physical Activity programme as a part of the rehabilitation and post-rehabilitation process.
D.1.1. Monitor the long term health related outcomes of the Adapted Physical Activity programme.
D.1.2. Determine the effects of the Adapted Physical Activity programme on functional ability of the patients/clients in collaboration with rehabilitation team.
D.2. Evaluate the patient’s/client’s response to physical activity, his/her progress, and compare with the preset goals.
D.2.1. Assess and evaluate the patient’s / client’s physical and psychological well being and its progress, and remediate if necessary.
D.2.2. Assess the motivation of the patient/client toward the Adapted Physical Activity programme, and remediate if necessary.
D.2.3. Monitor and assess the responses to physical activity to ensure safe and successful participation.
D.2.4. Document individual development and progress according to the aims of the rehabilitation and the APA programme.
D.2.5. Identify tools, methods, etc… to optimise the patient’s / client’s functional abilities in daily life and in physical activity.
Table 3: EUSAPA Functional Map – Rehabilitation, adapted from EUSAPA (2010) Appendix 3.
European Opportunities for Participation
A detailed list of European organisations, campaigns and initiatives providing people with disabilities opportunities to participate in sport can be found in the Council of Europe’s ‘Good Practice Handbook, No. 3 – Disability Sport in Europe, Learning from experience’: http://unescoittralee.com/wp-c... that Organisations Face
Some common barriers to inclusion in sporting activities for people with disabilities have been identified as (DePauw & Gavron, 2005; Hutzler & Sherrill, 2007):
- Lack of early experiences in sport (this varies between individuals and whether a disability is from birth or acquired later in life)
- Lack of understanding and awareness of how to include people with a disability in sport
- Limited opportunities and programmes for participation, training and competition
- Lack of accessible facilities, such as gymnasiums and buildings
- Limited accessible transportation
- Limiting psychological and sociological factors including attitudes towards disability of parents, coaches, teachers and even people with disabilities themselves
- Limited access to information and resources
Different. Just like you. A psychosocial approach promoting the inclusion of persons with disabilities.
This Danish Red Cross handbook (2015) provides practical guidance for organisations and professionals on how to facilitate safe and inclusive sport and APA:
https://www.icsspe.org/sites/d... possible, select locations that are screened off from the general public.
Before activities begin, all facilitators, helpers and participants should do a safety check on the playing field. Dangers might include glass, garbage, plastic bags and wrappings, animal excrement, sharp rocks, wood or any other debris that could cause injury to participants. Use locations that are safe for all users (e.g. stay away from rivers, embankments, cliffs, roads, etc). Make sure there is enough space for all of the participants to do the activity. Make sure there is enough equipment for everyone and that it is the correct equipment for the activity wherever possible. Make sure it is safe to get to and from the playing field, if a sports activity is held outside (e.g. no travelling in the dark). Changing rooms and bathrooms should be available, wherever possible. First aid kits should be available and all facilitators trained in using them. Be aware of participant’s pre-existing health conditions (e.g. asthma, diabetes), psychological/emotional problems or current illnesses or risk conditions. Always plan each session and ensure that the activities are suitable for the participants. Rival groups should not be involved in competitive games. If competitive games are played, rival group members could play in mixed teams. Choose activities carefully to promote cooperation. Make sure that participants choose team members in a fair way and in a manner that does not demean anyone. For example, if two team captains choose team members in turn, someone will be left at the end, feeling they are not wanted in any team. Be sure that there are enough facilitators and helpers for each session so that the participants are supervised well and are not at risk of harm. Facilitators should be trained in risk management.
Organisers promote inclusion by building on individuals’ strengths and interests, rather than focusing on their impairments.
The key elements in this approach are:
- Do not underestimate the person’s abilities.
- Have a plan for positive experiences by setting challenging but achievable goals.
- Have a flexible approach to coaching and communication that recognizes individual differences.
- Be creative and explore new and unconventional methods to ensure that every session is fun and rewarding for all.
- Be aware that there are different impairment groups (blind, deaf, learning disabled and physically disabled) that need different adaptations and that safety, (both physical and mental), is very important.
The Inclusion Spectrum
Developed by Black and Stevenson (2011), this model (figure 2.) is now widely used for the design and implementation of inclusion for all in physical education and sport.
The model classifies activities into 5 different groups based on the level of adaptation required:
- Open – minimal or no adaptations to the environment or equipment; open activities are by their nature inclusive so that the activity suits every participant.
- Modified - everyone plays the same game or performs the same activity but the rules, equipment or area of activity are adapted to promote the inclusion of all individuals regardless of their abilities.
- Parallel - although participants follow a common activity theme, they do so at their own pace and level by working in groups based on their abilities.
- Separate/Alternate - emphasises that, on occasions, it may be better for a person to practice sports individually or with their disabled peers.
- Disability/APA - ‘reverse integration’ where non disabled people are included in disability sports together with disabled peers.
- STEP tool - enables organisers to adapt the activity across the key areas of Space, Task, Equipment and People.
Figure 4: The Inclusion Spectrum incorporating STEP (Black & Stevenson, 2012) adapted from England Athletics: https://www.englandathletics.org/shared/get-file.ashx?itemtype=document&id=10176
Development of preventative and health conscious habits
Persons with disabilities have lower levels of physical activity than their peers, consequently 38% of the population is obese (53% more than people without disabilities), and engage in lower levels of physical activity. High costs for health services caused by overweight (increased blood pressure, diabetes Type 2, Hypercholesterolemia, stroke, osteoarthritis, sleep apnea, etc.) are a huge problem for the European tax payers.
- A review of the literature (Zakus, Njelesani & Darnell, 2007) on sport, physical activity and health demonstrated:
- Cardiovascular health benefits occur at moderate levels of physical activity and increase at higher levels of physical activity and fitness (General, 1996).
- Exercise is effective in the management of diabetes, as it has been shown to improve glucose homeostasis (Warburton, Nichol & Bredin, 2006).
- Both obesity and physical inactivity have similar patterns of association with clinical risk factors, such as blood pressure (Blair & Church, 2004).
- Obese individuals with at least moderate cardio respiratory fitness have lower rates of cardiovascular disease (Blair & Church, 2004).
- 40% of all cancers may be prevented by a healthy diet, physical activity and not using tobacco.
- Regular physical activity is an effective secondary prevention strategy for osteoporosis, as well as the maintenance of bone health.
- Exercise can be effective in improving mental well-being largely through improved mood and physical self-perception (Fox, 1999).
Parnes & Hashemi (2007) highlighted the health benefits of physical activity specifically for persons with disabilities:
- Persons with Disabilities share many traits with the general population, suggesting that the positive effects of physical activity on cardiovascular diseases are also attributable.
- Individuals disabled by osteoarthritis of the knee may benefit from aerobic and/or resistance exercise programs in the areas of physical performance and pain management (Ettinger et al., 1999).
- Physical activity and sport participation result in improved functional status and quality of life among persons with selected impairments and disabilities (Heath & Fentem, 1997).
- Children and adolescents with cerebral palsy may benefit from physical activity through improvements in strength and ability to walk, run, jump and climb stairs after participating in a strength-training program (Dodd, Taylor & Graham, 2003).
- Aerobic dance may affect cardiovascular endurance of adults with intellectual disabilities (Cluphf, O’Connor & Vanin, 2001).
- Physical activity may lead to improvements in physical health and well-being. Specifically, improvements have been noted in coordination, postural alignment and normalization of muscle tone, improved sitting balance and strength and rhythmical movements of the upper body (DePauw, 1986).
- Aerobic (endurance training) exercise is effective in improving general mood and depressive and anxiety disorders in select psychiatric patients. There is no harm associated with participation in physical activity and exercise in these populations (Meyer & Broocks, 2000).
- Participation in sports and physical fitness activities has been associated with three empowerment outcomes: perceived competence as a social actor; facilitation of goal attainment (including setting and pursuing goals, determination, and competitiveness); and social integration (including bonding, broadening social skills and experiences, and increased social inclusiveness) (Blinde & Taub, 1999).
- Romano-Spica et al., (2015) highlighted that advances in APA technologies and the scientific evidence to date indicates physical activity is a priority tool in the prevention of multifactorial diseases and sedentary lifestyle.
Incorporating sport and APA into rehabilitation services as well as post-rehabilitation community services, as outlined in this chapter, provides an effective means of improving the physical activity levels of persons with disabilities, ultimately improving the health and well-being of this population.
In 2016, Tom suffered a brain injury and underwent two brain surgeries. As a result he initially lost all mobility and suffered facial paralysis, affecting his ability to swallow. Tom spent 5 months as an inpatient in hospital. When being discharged from hospital Tom was able to walk with support for very short periods of time in the home, but required the use of a wheelchair when travelling outside.
As a result of his injury Tom experienced left-side weakness and had difficulties with memory, concentration and fatigue. He now needed support in performing everyday tasks such as getting dressed, cutting food and tying his shoe laces.
“I was motivated to improve my mobility as I have two sons who live abroad that I would like to be able to visit… but I lacked the confidence to engage in physical activity.”
The Community Brain Injury Team Physiotherapist informed Tom of Brain Injury Matters’ Sports 4 U programme. Sports 4 U involves a Physiotherapist-led exercise programme specifically designed for people with acquired brain injury, followed by workshops aimed at improving overall health and well-being.
Tom’s wife describe the timing of the programme as “a god send, both physically and mentally for Tom.” Since starting the programme Tom has made tremendous progress and reports enjoying “being part of a group that share similar experiences.”
Having just been signed off to walk up and down the stairs independently before commencing the programme, Tom is now jogging for the first time since his injury and reports using the ‘SMART’ goals discussed in the Sports 4 U workshops to increase the distance he walks outside of the programme.
“I now have the confidence to go places we haven’t been since my injury, like the cinema… and to sign up for another physical activity programme with the GP.”
“We were able to visit our son in Scotland, our next goal is to visit our son who lives in America.”
Tom’s wife said “we couldn’t speak highly enough of Brain Injury Matters and the work they have been doing; we would thoroughly recommend the Sports 4 U programme to anyone in a similar situation.”
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