Exploring sport participation in individuals with spinal cord injury: A qualitative thematic synthesis

Abstract

Context

Individuals with spinal cord injury (SCI) are susceptible to various physical, psychological, and social challenges. Sport is an activity that may holistically address these concerns. No existing research provides an overview of the current landscape of SCI-specific sport participation.

Objective

To synthesize the findings of qualitative studies exploring the perceptions of people with SCI participating in sport, in relation to physical, psychological, and social health.

Methods

This thematic synthesis included studies published in APA PsycInfo, CINAHL, Embase, Emcare, Medline, and PubMed. Eligible articles studied adults who had a SCI for ≥12 months and explored experiences following ≥3 months of sport participation using qualitative or mixed-methods. Articles were excluded if participants with SCI composed less than one-third of the study sample. From 8473 unique titles and abstracts screened, 47 articles underwent full-text review and 14 articles were included. The Mixed Methods Appraisal Tool was used to critically appraise the 13 qualitative studies and one mixed-methods study.

Results

The overarching theme was that sport facilitates the progression to living an enriching life with SCI. Four sub-themes were identified within this theme: adjusting to SCI, factors influencing sport initiation, outcomes resulting from sport participation, and reshaping views of SCI. Participants detailed many benefits of sport, including improved fitness, independence, confidence, and sense of community. Beyond the participants themselves, sport helped reshape views of SCI by breaking stereotypes and inspiring others.

Conclusion

Sport can play a crucial role in facilitating the progression to living an enriching life following SCI.

Introduction

Spinal cord injury (SCI) is a life-altering condition that occurs as a result of traumatic or non-traumatic damage to the spinal cord.¹ Individuals affected with a SCI experience significant impairments to sensory, motor, and autonomic function,² as well as encounter various psychological and social challenges.¹ For instance, those living with a SCI are at high risk for depression, social isolation, unemployment, and reduced community participation.¹ Considered together, the impairments arising from SCI affect individuals’ physical, psychological, and social functioning and ultimately influence their overall wellbeing.³ Given the multi-faceted challenges associated with SCI, a holistic approach is recommended to target these issues simultaneously.⁴

Sport is a holistic activity that shows promise for people living with a SCI.^1,3 “Sport” is defined as a physical activity involving exertion, skill, and/or hand–eye coordination as the primary focus, with elements of competition and formally existing through organizations.⁵ Sport includes both team and individual sport and can manifest on the recreational and elite level. Moreover, sport often takes place in social contexts and is associated with improved psychological and social health, in addition to its physical benefits. A model summarizing the role of sport in health highlights the impact of sport on the overlapping domains of physical, psychological, and social health. As defined by Eime et al., “physical” refers to the body or processes of the body, “psychological” refers to the mind or processes of the mind, and “social” refers to the interactions or sense of interactions among individuals.⁶

There is limited research synthesizing the impact of sport for those with a SCI. Existing literature lacks focus on SCI and instead summarizes the outcomes of sport for people with disabilities as a whole, such as for individuals with intellectual disabilities,^7,8 neurological disabilities,⁹ and physical disabilities.¹⁰ Given the unique challenges associated with SCI (i.e. impairments to autonomic function in addition to sensory and motor deficits²) and distinct demographics of this population (i.e. typically adult onset unlike congenital cerebral palsy and spina bifida; younger age of onset unlike in stroke^11,12), a detailed review of the literature is needed to gain an in-depth understanding of the complete experience of sport in the SCI population. The reviews that do focus on SCI either examine physical activity or exercise and not sport,^13,14 or are narrative reviews and do not offer a comprehensive summary of the existing sport research.^15–17 Only one systematic review to our knowledge has examined sport and SCI; however, this study only reported on psychosocial outcomes.¹⁸

No research to date has synthesized the existing body of qualitative research on the overall impact of sport participation for individuals with SCI. Given that detailed insight on individuals’ thoughts, emotions, and experiences are often missed during formal clinical interactions,¹⁹ qualitative research is a useful method that helps shed light on these unique experiences and social dynamics.²⁰ Moreover, a synthesis of this qualitative research will offer a comprehensive exploration of social phenomena, which aims to describe, in contextualized detail, key recurring messages from a group of studies.^19,21 This description is of particular importance as it offers an enhanced interpretation that goes beyond the results of primary studies.²² Specifically, synthesizing qualitative research will help us gain an in-depth understanding of peoples’ perceptions on how sport impacts physical, psychological, and social well-being, and use the new knowledge to inform future adaptive sport programs. Therefore, the purpose of this review was to synthesize qualitative studies exploring the experiences of people with SCI participating in sport programs, in relation to physical, psychological, and social health.

Materials and methods

Study design

A qualitative thematic synthesis was conducted.²³ This methodology aims to integrate the findings of qualitative studies in a way that most closely preserves the results of primary research.²³ Three steps were involved: line-by-line coding, development of descriptive themes, and generation of analytical themes.²³ This technique was selected as a structured method to transparently synthesize and analyze the findings of multiple qualitative studies.²³

This review was registered on the Open Science Framework (https://osf.io/xvckf) and followed the Enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) guidelines.²² These guidelines consist of 21 items and provide a framework for explicitly and comprehensively reporting the synthesis of qualitative health research.²² This qualitative synthesis was part of a larger search strategy for a scoping review that also aimed to identify quantitative studies investigating the impact of sport participation post-SCI.

Article identification

Articles were identified following consideration of the relevant Population, Concept, and Context (PCC). The Population of interest was adults with SCI; the Concept was sports; and the Context was sport programs outside of rehabilitation or laboratory settings.

The following electronic databases were searched from inception to January 19, 2021: APA PsycInfo, CINAHL, Embase, Emcare, Ovid Medline, and PubMed (non-Medline). This pre-planned search strategy was developed in collaboration with an Information Specialist (MP). No date or language limits were applied. Minor publication types (i.e. abstracts, notes) were excluded. To keep the results of this search strategy as comprehensive as possible and to ensure no articles were missed, only two of the PCC elements were used: Population = spinal cord injured and disabled wheelchair athletes and Concept = sports. An example of one database search strategy is available in the Appendix.

Duplicate results were removed on EndNote, a reference management tool,²⁴ and then uploaded to Covidence, a production platform for systematic reviews.²⁵ Three researchers (LC, KC, and MGH) identified qualitative studies. Two researchers (LC and KEM) then completed the title and abstract screening of those qualitative studies. Next, two researchers (LC and BM) completed full-text review. Articles written in a language other than English were translated using Google Translate²⁶ and verified by a native speaker. Authors of studies were contacted via email to obtain any missing information that prevented an inclusion or exclusion decision to be made. Conflicts that arose during these processes were resolved through discussion until consensus was reached.

Inclusion and exclusion criteria

Articles were included if they: (a) studied adults aged ≥16 years who were ≥12 months post-traumatic or atraumatic SCI, of any level of impairment, level of injury, and mobility status; (b) explored the physical, psychological, and/or social impacts resulting from participation in organized team or individual sports for ≥3 months; (c) focused on sport outside of hospital- or clinic-based rehabilitation programs or laboratory settings; and (d) used qualitative or mixed-method study designs. Dissertations were also eligible for inclusion.

Articles were excluded if they studied individuals with neurological conditions that were not SCI or if the sample was composed of a mixed population in which ≤1/3 of participants had SCI. Rehabilitative physical activity (e.g. recreational therapy), activities of daily living, occupational physical activity, and leisure-time physical activity and exercise that does not fall under the definition of a sport (e.g. leisure walking) were excluded. Studies investigating the impact of sport pre-SCI or exploring SCI resulting from sports participation were also excluded. Articles were also excluded if sport took place in the rehabilitative (i.e. hospital, rehabilitation clinic) or laboratory settings. All quantitative studies, conference proceedings and abstracts, textbook chapters, and reviews were excluded.

Data extraction and critical appraisal

Data extraction was completed by one author (BM) (Table 1). Data regarding study details were extracted, including year of publication, study objective, and methodology. Participant-specific information was also extracted, such as sex, age, injury details, and sport details. A final column listed themes generated from each study.

Table 1.

Description of included articles describing experiences of sport participation for individuals with SCI (n = 14).

Author(s)	Year	Methodology	Objective	Eligible Participants with SCI/Total (%)	Sex	Age (years) M ± SD (range)	SCI Details (neurological level of injury, severity of injury)	Duration of Injury (years) M ± SD (range)	Sport Details	Duration of Sport Participation (years) M ± SD (range)	Themes
Allan et al.	2018	Narrative research	To explore the meanings that shape sport participation overtime within athletes’ narrative types	10/21 (48)	M/F	33.7 ± 14.5 (19–73)*	NR	12.3 ± 9.60 (2–35)*	Adapted waterskiing, boccia, hand-cycling, para-alpine, para-archery, para-athletics, para-Nordic, para-rowing, para-swimming, para-triathlon, power wheelchair hockey, sitting volleyball, sledge hockey, wheelchair basketball, wheelchair curling, wheelchair rugby, etc*	10.9 ± 8.90 (2–35)*	Meta-theme: Feeling equal and valued - A Cinderella story - From ordinary to extraordinary - Holding on - Letting go - Embracing change
Ciampolini et al.	2014	Qualitative description	To examine the psychosocial benefits of 18 months of wheelchair tennis	2/6 (33)	M/F	(30–55)*	NR	(4–15)*	Wheelchair tennis	1.50	- Practice for health - Practice for representation
Côté-Leclerc et al.	2017	Sequential explanatory mixed methods	To explore the influence of sport participation on quality of life	8/10 (80)	M/F	39.2 ± 11.1*	Paraplegia (n = 6), tetraplegia (n = 2)	NR†	Athletics, adapted tennis, rugby, paracycling, basketball, other*	9.40 ± 8.70*	- Personal factors - Social participation - Environment
Crawford et al.	2014	Phenomenology	To explore the influence of sport participation on post-traumatic growth following SCI	12/12 (100)	NR	40.7 ± 9.96 (24–55)	NR	18.8 ± 9.54	Wheelchair racing, basketball, rowing, alpine ski racing, paracycling, rugby, water- skiing, sledge hockey, baseball, sailing, tennis, etc	NR§	- Injury relevant processing - Appreciation for life - Reactive behavior as a result of attempted integration into ParaSport - Relating to others - Health and well-being
Garci et al.	2005	Qualitative description	To explore the meanings given to sport engagement in wheelchair basketball	8/16 (50)	M/F	34.9 ± 6.31 (29–46)a	NR	7.00 ± 3.94b	Wheelchair basketball	13.3 ± 4.80 (5–21)§c	- The love of the game - Esprit de corps - Raising the bar
Goodwin et al.	2009	Phenomenology	To explore the influence of wheelchair rugby on sense of community	11/11 (100)	M/F	33.0 (22–48)	Paraplegia (n = 1), tetraplegia (n = 10)	15.0 (5–31)	Wheelchair rugby	9.00 (3–20)	- It’s okay to be a quad - Don’t tell us we can’t - The power of wheelchair rugby
Hawkins et al.	2014	Qualitative description	To examine how sport and athletic identity assists in adjustment to SCI	8/8 (100)	M/F	36.3 ± 8.10 (22–46)	Paraplegia (n = 7), tetraplegia (n = 1) Complete (n = 4), incomplete (n = 4)	11.5 ± 8.30 (3.5–26)	Wheelchair badminton	NR§	- Adjustment and paradox of chronic illness - The role and value of an athletic identity
Kotewa	2014	Phenomenology	To explore the experiences of participation in competitive wheelchair basketball	6/7 (86)	M/F	24.8 ± 4.88 (20–33)	NR	NR†	Wheelchair basketball	5.00*	Independence - Sources of support - Choice and opportunities - Try new things Advocacy - Navigating barriers - Role models - Asking for help
Litchke et al.	2012	Phenomenology	To examine the meanings and impact on life attributed to wheelchair rugby participation	4/5 (80)	M	29.3 ± 6.02 (21–35)	Tetraplegia (n = 4) Complete (n = 4)	12.3 ± 6.02 (4–18)	Wheelchair rugby	8.50 ± 6.81 (3–17)	- Physical health - Psychosocial well-being - Full contact sport - Athletic identity is important
Machida et al.	2013	Phenomenology	To understand the influence of sport participation on the experiences of individuals who encountered trauma	12/12 (100)	M	(21–41)	Tetraplegia (n = 12) Complete, incomplete	NR†	Wheelchair rugby	(1–18)	- Pre-existing factors and experiences - Disturbance /disturbing emotions - Multiple sources and types of support - Special opportunities and experiences - Various behavioral and cognitive coping strategies - Motivation to adapt - Gains from the resilience process
Piletic	1999	Phenomenology	To determine the reasons for participation in competitive powerlifting	5/12 (42)	M	37.4 ± 5.13 (32–43)	Tetraplegia (n = 1), paraplegia (n = 4) Complete (n = 1), incomplete (n = 4)	17.4 ± 4.77 (12–22)	Powerlifting	13.3 ± 12.2 (1–27.5)	- Empowerment - Physical awareness - Camaraderie - Independence - Victimization
Schmid et al.	2019	Qualitative description	To evaluate the organizational outputs and participant outcomes from an adaptive surf program	4/6 (67)	M/F	(30–64)*	Tetraplegia, paraplegia	NR†	Surfing	3.88 ± 4.17 (1–10)	AccesSurf’s Process & Outputs - Positive atmosphere - Opportunities - Enjoyment and excitement: Fun - AccesSurf volunteers - Natural settings and type of activity: Surfing - Duke’s Oceanfest Participants’ Outcomes & Effects - Immediate outcome - Long-term outcome - Effects
Stephens et al.	2012	Qualitative description	To investigate the reasons for sport engagement and to identify barriers to participation	7/7 (100)	M/F	37.9 ± 8.11 (26–49)	Tetraplegia (n = 4), paraplegia (n = 3) Complete (n = 6), incomplete (n = 1)	13.4 ± 10.1 (4–33)	Wheelchair basketball, rugby, tennis	NR	- Perceived benefits - Perceived barriers
Stillson	2007	Case study	To identify factors contributing to sport engagement and to explore the perceived benefits and barriers to participation	9/11 (82)	M/F	34.4 ± 11.5 (20–54)	Paraplegia (n = 8), NR (n = 1) Complete (n = 8), NR (n = 1)	15.9 ± 10.6 (1–35)	Wheelchair racing	NR	- Initial sport involvement - Prior sport involvement - Present sport involvement - Benefits of post-injury sport involvement - Barriers to post-injury sport involvement - Meaning of being team involved - Individual stories from interviews - Personal observations and conversations

M = Male, F = Female, NR = Not Reported.

*SCI-specific data not provided.

†Assumed ≥ 12 months, as duration of sport participation ≥ 12 months.

§Assumed ≥ 3 months, as participants engaged in high-level competitive sport (i.e. club, provincial, national, international level).

^aCalculated based on data provided in original article.

^bCalculated based on information provided for 5 of 8 eligible participants.

^cDuration of sport participation includes pre-SCI sport participation.

One author (LC) engaged in critical appraisal using the Mixed Methods Appraisal Tool (MMAT) (Table 2). The MMAT is a critical appraisal tool developed for systematic reviews consisting of studies of varying methodological designs. This tool used two screening criteria and five criteria for the assessment of methodological quality. Given that the MMAT discourages the calculation of an overall score of quality for each article, a detailed presentation of each criterion rating was used.²⁷

Table 2.

Critical appraisal of using the mixed-methods appraisal tool (MMAT).

Author(s)	Year	S1	S2	1.1	1.2	1.3	1.4	1.5
Allan et al.	2018	Y	Y	Y	Y	Y	Y	Y
Ciampolini et al.	2014	Y	Y	Y	Y	N	N	N
Côté-Leclerc et al.	2017	Y	Y	Y	Y	Y	Y	Y
Crawford et al.	2014	Y	Y	Y	Y	Y	Y	Y
Garci et al.	2005	Y	Y	Y	Y	N	Y	N
Goodwin et al.	2009	Y	Y	Y	Y	Y	Y	Y
Hawkins et al.	2014	Y	Y	Y	Y	Y	Y	Y
Kotewa	2014	Y	Y	Y	Y	Y	Y	Y
Litchke et al.	2012	Y	Y	Y	Y	Y	Y	N
Machida et al.	2013	Y	Y	Y	Y	Y	Y	Y
Piletic	1999	Y	Y	Y	Y	Y	Y	Y
Schmid et al.	2019	Y	Y	Y	N	Y	Y	Y
Stephens et al.	2012	Y	Y	Y	Y	Y	Y	Y
Stillson	2007	Y	Y	Y	Y	Y	Y	Y

Studies were assessed using S1 and S2. Next, qualitative studies were assessed using qualitative criteria 1.1–1.5 and mixed-methods studies were assessed using mixed-methods criteria 5.1–5.5 (item 5.5 mandates the evaluation of both qualitative and quantitative components individually). Given that only the qualitative components of studies were synthesized for the purposes of this review, this table lists only scores for each study.

S1. Are there clear research questions?

S2. Do the collected data allow to address the research questions?

1.1. Is the qualitative approach appropriate to answer the research question?

1.2. Are the qualitative data collection methods adequate to address the research question?

1.3. Are the findings adequately derived from the data?

1.4. Is the interpretation of results sufficiently substantiated by data?

1.5. Is there coherence between qualitative data sources, collection, analysis and interpretation?

Qualitative thematic synthesis

The synthesis technique was derived from the steps outlined by Thomas and Harden.²³ The findings or results section was extracted to create “transcripts”. The line-by-line coding stage started with LC, BM, and KEM coding one article together to facilitate consistency between authors. Coding involved labeling texts of interest (e.g. “all my worries, all my fears, all my thoughts just disappeared, and became about [parasport]”²⁸) with a code (e.g. “Sport as an outlet”). Using this inductive approach, initial codes for the codebook were created. The codebook, available for reference in the Supplementary Material, provided a structured layout for the analyzed data and was refined as coding progressed. Next, LC and BM coded two more articles separately, after which new codes were discussed and then added to the codebook. The same process between LC and BM occurred for the next three articles, totaling six completed articles. Because new codes were consistent between LC and BM, the two authors then coded four articles each, after which line-by-line coding was complete and the codebook was finalized. The next step consisted of developing descriptive themes, where codes were re-organized and grouped together in a logical manner through discussion between LC, BM, and KEM. These groupings led to the development of descriptive themes in the final codebook. Lastly, the finalized codebook with descriptive themes was re-applied to all transcripts. During this process, analytical themes were generated, in which authors went “beyond” the content of the included studies to target the review question.²³ These analytical themes were developed first individually and then as a group to tie ideas from all studies together and to address the primary research question. This synthesis technique was also applied to studies comprising of a mixed population, although quotes were only extracted from participants with SCI.

Results

Included studies

The search across databases yielded a total of 8473 articles following de-duplication. After title and abstract screening, 47 studies were assessed in the full-text review stage and 14 studies were selected for inclusion.^28–41 Figure 1 contains the PRISMA flow diagram summarizing the review process.⁴²

Figure 1.

PRISMA flow diagram describing the article selection process.

Thirteen of the 14 included studies were of qualitative design, composed of phenomenology (n = 6), qualitative description (n = 5), narrative research (n = 1), and case studies (n = 1), and the one mixed-methods study used a sequential explanatory design. Eight studies comprised a mixed population and six studies included only individuals with SCI. Of 144 total participants, 106 athletes with SCI were included. Ten of the 14 studies contained a mix of female and male participants, of which the remaining consisted of either only males or were unspecified. Eleven studies consisted of participants with a mean age under 41 years and three studies listed broad age ranges. Sports included wheelchair racing, basketball, rugby, tennis, badminton, powerlifting, athletics, and water sports (i.e. surfing, rowing, swimming). Full study characteristics are described in Table 1. Qualitative methodological quality scores from the 14 studies are summarized in Table 2.

Synthesis of results

The overarching theme that emerged was that sport facilitates the progression to living an enriching life with SCI. Four sub-themes are captured within this overarching theme: (1) adjusting to SCI; (2) factors influencing sport initiation; (3) outcomes resulting from sport participation; and (4) reshaping views of SCI. Each sub-theme consists of several categories and sub-categories, outlined in Table 3. A graphic representation of these themes is depicted in Figure 2, which portrays the shape of an hourglass to signify the role of sport over time for those with SCI. Additional quotations by participants are available in the Supplementary Material. Italicized quotations represent statements made by participants of included studies and non-italicized quotations represent statements made by authors of included studies.

Table 3.

Identified sub-themes, categories, and sub-categories.

Sub-themes	Categories	Sub-categories
1. Adjusting to SCI	(a) Disturbance to life	Disturbance to function Disturbance to identity
	(b) Coping and growth	Importance of mindset Importance of support
2. Factors influencing sport initiation	(a) Facilitators to initiating sport	Family, peers, and mentors Rehabilitation facilities with sport Pre-injury sport participation
	(b) Barriers to initiating sport	Coming to terms with disability Messages in healthcare
3. Outcomes resulting from sport participation	(a) Benefits of sport participation	Improving strength and independence Preventing secondary complications Improving mental health Growing and reshaping themselves Having an outlet Learning with and from others Finding their community Having competition Feeling “normal” Accepting their injury
	(b) Challenges of sport participation	Individual factors Logistics of traveling Finances
4. Reshaping views of SCI	(a) Breaking stereotypes	–
	(b) Teaching and inspiring others	–

Figure 2.

Diagram depicting the overarching theme and sub-themes. Sub-themes 1 and 2 are located at the top of the hourglass, as they occurred leading up to sport participation, and sub-themes 3 and 4 are located at the bottom of the hourglass, as they occurred as a result of sport engagement.

Sub-theme 1: Adjusting to SCI

This brief section sets the context for participants’ sports participation, highlighting the struggles and growth experienced following the initial injury. Two categories are included within this sub-theme: (a) disturbance to life and (b) coping and growth.

Disturbance to life

Disturbance to function. Participants experienced drastic changes in function following SCI, contributing to what was described as a period of great disruption.^28,31,34,37 These changes included “not being able to provide for their family or loss of a job”,³⁴ a reduction in mobility and independence,³⁷ and not being able to engage in sport in the same manner as prior to the injury,^28,31 and were associated with “disturbing emotions, disturbing thoughts, and challenges”.³⁷ A participant with paraplegia described the intense grief following injury: “I was so angry and frustrated [pause] grieving for my able-bodied life”.³⁴

Disturbance to identity. In addition to functional disturbance, this period of disruption was compounded by a “huge blow”³¹ to participants’ self-esteem and identity. The shattered identity resulted in feelings of shock, depression, and helplessness^31,34 and consequently revealed to participants a need to “re-identify and rediscover [themselves]”.³¹ A participant described this process: “So then I lost my sexuality, the image that I was, everything was totally gone. I had to totally rebuild myself as a new person”.³¹

Coping and growth

The importance of mindset. To assist with the difficult transition to living with SCI, participants highlighted the importance of having a positive mindset.^28,31,36,37 This mentality facilitated growth and included shifting priorities to focus on family and friends, giving back to the community, and living “fully in the present”.³¹ This growth mindset was used to develop resilience by problem-solving through difficult activities such as transfers,³¹ seeing adversity as an opportunity for growth,³⁷ and striving for challenge and mastery.²⁸ The desire to grow and make the most of life was evident in participants and was a precursor to eventual sport involvement.

The importance of support. Not surprisingly, social support was described as a crucial factor in helping participants cope with injury and grow.^31,35,37 Participants had many different sources of support,^35,37 from family and friends to healthcare professionals and were encouraged by “people that still love [them]”.³¹ Not only did the support of loved ones enable growth but also “tough love”³⁷ pushed participants to strive for improvement.

Sub-theme 2: Factors influencing sport initiation

This section describes the factors that influenced participants’ introduction to sport. Two categories compose this sub-theme: (a) facilitators to initiating sport and (b) barriers to initiating sport.

Facilitators to initiating sport

Family, peers, and mentors. Not only were participants’ support networks important in helping individuals cope after injury, but they also played a significant role in the transition to sport participation.^28,35,41 Family members helped provide their loved ones with opportunities to access sport^28,35 and provided encouragement to support participants’ involvement.⁴¹ The father of a 20-year-old wheelchair racer with paraplegia became so involved that he attended team practices, traveled with her to the Paralympics, and even helped coach at a children’s rehabilitation hospital.⁴¹ Peers and mentors were also involved in introducing participants to sport through “‘have-a-go’ days”²⁸ or “SCI peer support program[s]”.⁴¹

Rehabilitation facilities with sport. Interestingly, only two studies reported the influence that rehabilitation facilities with sport programs had on the continued participation of individuals with SCI.^28,41 Three participants in Stillson’s dissertation were introduced to sport in rehabilitation through “recreation and the physical therapy departments”, brochures, and programs, where they were exposed to many sports.⁴¹

One participant expressed his enthusiasm for sport during rehabilitation: “I was introduced to so many different things and I wanted to do all of them … I was like, ‘I need to be competitive’ – I was trying to figure out which would I could be a Paralympian in”.²⁸

Pre-injury sport participation. Having an athletic identity from participating in sport prior to injury also influenced sport involvement.^{28,31,36,38,41} Participants emphasized: “I was always the ‘athlete’”³¹ “I cannot imagine not doing something athletic”,³⁶ and “I wasn’t done with [sport]”.²⁸ Participants engaged in sport throughout their lifetime or in childhood and used parasport to “fill a spot that [was] missing”³⁶ following SCI.

Barriers to initiating sport

Coming to terms with disability. Mental health challenges following SCI delayed initiation of sport.^{28,33,34,40,41} A 49-year-old wheelchair tennis player with paraplegia explained how “get[ting] over the hump”⁴¹ took precedence over sport engagement:

initially I was too focused on coming to terms with being able-bodied half of one year and disabled for the other half of the year so sport wasn’t really a focus of mine to start with. It was more about coming to terms with disability and finding a way to get back out there⁴⁰

Others stated that depression and mental illness,^28,34,40 “fear of being out there in the public”,⁴⁰ and taking time to adjust to their disability³³ prevented earlier sport engagement. Participants were required to accept their current state prior to showcasing themselves through sport.³³

Messages in healthcare. Lack of information and negative messages about sport from medical professionals prevented earlier engagement in sport.^28,33,40,41 Participants described how sport was neither promoted nor encouraged by doctors^33,41 and insufficient information on sport was provided during the acute phases of injury.⁴⁰ Instead, the focus “involved teaching the individuals whatever they might need and then sending them home”.⁴¹ One participant summarized the impact of these messages on participants’ physical activity choices following discharge: “When I was 12 the doctor said I’d never play sports again … So, from the age of 12 to the age of 20 there was no sport at all”.²⁸

Sub-theme 3: Outcomes resulting from sport participation

This section details the extensive benefits experienced following sport participation and the various challenges that were faced. Two categories are captured within this sub-theme: (a) benefits of sport participation and (b) challenges of sport participation. It is important to note that sub-categories are not segregated into physical, psychological, and social outcomes, as the benefits of sport often fell within overlapping domains.

Benefits of sport participation

Improving strength and independence. The majority of studies discussed the role of sport in improving functional strength and independence.^{28–31,34–36,38–41} Specifically, participants mentioned that engagement in sport increased their strength and fitness, resulting in a greater ability to complete daily activities such as transfers and personal care.^{30,31,36,38–41} Participants appreciated how sport assisted in weight management,^34,38,40,41 prevented the need for “extra equipment”,⁴⁰ reduced “the amount of assistance required”,³⁵ and helped get them out of the house.^31,41 Two athletes summarized how sport facilitated greater independence: “If I did not play rugby I would not be as healthy, happy, strong, confident, and independent as I am”,³⁶ and “I am more physical, able to do more things. I transfer. I am independent. I live on my own. I drive. I go to school So I do everything on my own”.³⁸

Preventing secondary complications. Engagement in sport was a factor that prevented secondary complications associated with SCI.^36,38,40,41 Participants noted reductions in urinary tract infections,³⁶ pain,^36,40 muscle spasms,⁴⁰ pressure sores,⁴⁰ medication dependency,³⁸ and hospitalizations.³⁸ Three studies^28,35,36 even reported that sport functioned as an alternative form of physical therapy or rehabilitation. Sport was described as “equal to more tradition[al] methods of physical therapy”³⁵ and “an aid in their recovery and rehabilitation”.²⁸

Improving mental health. It was not surprising that participants emphasized the positive impact sport had on their mental health.^{28,30,31,33,36,38,40,41} Sport helped mend the identity that was disrupted by their SCI and led to increased feelings of self-worth,⁴⁰ greater ability to “stay positive”,³⁸ improved body image,^30,38 and increased confidence.^{28,31,33,36,37,40,41} Sport not only made a difference in participants’ physical bodies, but it also influenced participants’ body image: “It is not perfect, but it looks good to me so that is all that matters”.³⁸ Moreover, participants explained how the “shared group experiences”³³ and “fruitful social participation”²⁸ facilitated the development of confidence both within and beyond the sport context. A 29-year-old rugby player with quadriplegia stated, “I am more confident even in situations that have nothing to do with rugby”.³⁶

Growing and reshaping themselves. Not only were participants’ mental health improved, but they were also able to grow and reshape themselves through sport.^{28,30,31,34,37,38,40} Participants explained how sport “turned their lives around”³⁷ by assisting in the “development of an athletic identity”,³¹ facilitating the “resilience process”,³⁷ and providing them with a new purpose in life.^28,40 Moreover, the “new lifestyle”⁴⁰ established through sport provided participants with a sense of accomplishment^30,38,41 and empowerment.^28,38 An athlete with paraplegia explained the ripple effect that sport achievement had on life: “it’s an accomplishment [that] spreads through everyone around you, through your whole life”.³⁰

Having an outlet. Interestingly, five studies described how sport functioned as an outlet.^{36–38,40,41} Sport was a means of releasing stress,³⁶ frustration,^37,40 and aggression,³⁷ as well as provided participants with a form of escapism and distraction from negative thoughts and emotions.^{28,37,38,40,41} Numerous participants highlighted this important role of sport: “it is nice being able to release stress through sport”;³⁶ “the way to keep my mind occupied is to do something structured and constructive, that is why I am involved in powerlifting”;³⁸ and “when I’m playing sport I can forget about everything and focus on that [sport]”.⁴⁰

Learning with and from others. Many studies described the importance of sport in facilitating learning between athletes.^{28,30,31,33,35–39,41} Sport provided participants with “a wealth of knowledge”³¹ from being in a community of people with similar experiences. Participants discussed being able to learn and share helpful tips for navigating challenges such as selecting appropriate equipment,³⁶ completing difficult transfers,³³ and addressing “bladder or bowel or sexual”⁴¹ concerns. A rugby player with quadriplegia emphasized, “I still learn a lot from other quads, that they do things a certain way that I didn’t know”.³³ Moreover, participants not only received mentorship as they navigated sport, but they also provided mentorship and passed on knowledge to newer athletes^33,35,39,41: “whatever you do in life you need to pass it on”⁴¹ and “there are things I can teach XY, but, he’s definitely taught me some stuff”³⁹. Additionally, participants were able to engage in novel experiences and learn with each other by “doing other sports that [they] wouldn’t normally”,³¹ “try[ing] new interests”,³⁵ and traveling around the world.^36,38,41

Finding their community. All studies noted that sport helped participants find their community.^28–41 Importantly, sport allowed athletes to engage in unique social interactions that may not otherwise have been possible with able-bodied individuals. A wheelchair rugby player explained, “My able bodied friends […] They don’t really understand what I’m going through. […] that’s why we talk about it here. You’re allowed to share”.³³ Other participants described sport as “reducing the feeling of social isolation”,⁴⁰ allowing them to be around people who “understood what it was like to be disabled”,⁴¹ and increasing camaraderie,^33,36,38,41 sense of belonging,^28,33,35 socialization,^29,30,34 and social support.^31,35 Furthermore, athletes were bound to each other by a “sharing of ties”³³ through common experiences and interests.^30,31,33,37 The connections developed from being part of a team^36,38,41 allowed participants to view their teammates as family.^32,35,37 Importantly, playing alongside a group of like-minded individuals allowed participants to have fun;^28,32,39,41 “I get to have just fun with all my friends out there, and we’re not worrying about any disabilities”.³⁹

Having competition. An interesting benefit of sport was that it allowed participants to experience aspects of competition.^{28,29,31–33,36,38,40,41} Specifically, several wheelchair rugby players appreciated the physicality of the sport: “Rugby players are drawn to the sport at least partially because of this contact”;³⁶ “even though I can’t walk and run around, I can still play full contact in a chair”;³³ and “It’s the contact.   …  It’s just the chair hitting the chair”.³³ Moreover, participants felt the competitive aspect of sport motivated them to set heightened goals and strive for improvement.^{28,29,31–33,40,41} A 26-year-old male with quadriplegia stated, “I see people that can do it, so I know it can be done […] It definitely pushes me harder”.⁴⁰ Participants also explained how competition through sport meant “proving oneself as a superior athlete”,²⁸ earning “respect because of their competitive ability”,³⁸ gaining confidence from athletic accomplishments,³⁸ and taking responsibility for the outcomes.^38,41

Feeling “normal”. Sport also allowed participants from three studies to feel a sense of normalcy.^28,35,41 Through sport, participants were able to connect with others of similar circumstances, “feel ‘normal’”,²⁸ and “hav[e] a sense of equality with peers”.³⁵ Moreover, not only were participants able to play alongside other individuals with disabilities, but they were also “exposed to opportunities to participate alongside able-bodied friends and family”.²⁸ A 43-year-old wheelchair racer with paraplegia explained how important racing with able-bodied individuals was to him: “just competing with all the runners […] although obviously you’re different but you’re in the same race and doing the same distance … for me anyway it’s a big deal”.⁴¹

Accepting their injury. Sport played an important role in further facilitating acceptance of SCI in participants as well as in their families.^{28,33–36,38} Through all the growth experienced during athletic engagement, sport “empowered [participants] to accept [their] disability, overcome [their] fears, and live life to the fullest”.²⁸ Sport helped participants become more willing to accept help and ask others for assistance.^35,36 Furthermore, sport helped participants’ families accept SCI; a female wheelchair rugby player with quadriplegia recalled: “When I got injured it hurt them [my family] all really bad … and they’re all blown away by what they saw and that helps a lot”.³³

Challenges of sport participation

Individual factors. Participants described various individual factors that challenged their sport involvement, including dealing with physical health and navigating the transition to parasport.^{28,30–32,40,41} Physical challenges included: musculoskeletal injuries caused by “playing sports intensively”,³⁰ pressure ulcers,⁴¹ urinary tract infections,⁴⁰ acid reflux,⁴¹ and back pain.⁴¹ From a participation standpoint, one athlete mentioned that “he found learning a new sport psychologically challenging because he was unable to return to his pre-injury abilities”.³¹ Moreover, participants were required to make sacrifices to train and compete, such as missing out on social events with family or friends.^30,32

Logistics of traveling. Four studies commented on the logistical difficulties associated with traveling, which were experienced by participants ranging from recreational to elite sport.^30,34,40,41 Firstly, leaving the home required planning: “there is much more planning and preparation needed to get from A to B”⁴⁰ and “it takes me longer to get ready in the morning. Everything needs to be planned”.³⁴ Secondly, transporting equipment in an apartment or on airlines was difficult and described as “not as easy to do”.⁴¹ Furthermore, participants described being faced with the challenge of navigating inaccessible facilities, including hotels, gyms, and parking lots.^34,41

Finances. The financial challenges associated with participating in both recreational and elite sport were described as hurdles for athletes.^{28,30,35,40,41} Participants expressed that the lack of financial resources available^35,40 and the expensive sporting equipment^30,40,41 posed challenges for sport engagement. For example, athletes stated, “a lot of the teams just can’t afford to play any more”⁴⁰ and “equipment is a massive barrier. It’s just not as expensive in able-bodied sport”.⁴⁰

Sub-theme 4: Reshaping views of SCI

The outcomes of sport participation extended broader than the participants themselves. Athletic engagement contributed to the reshaping of views regarding disability, SCI, and sport. This sub-theme consists of two categories: (a) breaking stereotypes and (b) teaching and inspiring others.

Breaking stereotypes

Sport enabled participants to break stereotypes of SCI and to be viewed as an athlete.^{28,32,33,35,36,38,40,41} Participants highlighted how sport challenged conventional views of SCI held by the general population, such as the stereotypes of being “fragile and passive”,³³ “confined to the wheelchair”,³⁸ “disabled”,^28,32,38,41 “sedentary”,³³ and “sit[ting] at home […] do[ing] nothing”.⁴⁰ Athletes explained, “I was doing it [sport] in a lot of ways to beat my disability”²⁸ and “we challenge what people think people with disabilities are able to do”.³⁵ Participants from several studies^{28,32,36,38,41} also mentioned a desire and appreciation for being “recognized […] as athletes, not as a bunch of disabled people”.³² Furthermore, two studies explained how sport helped participants reframe their own views of SCI^28,38: “their development in parasport led to a major transition in the way they viewed themselves both as athletes and as people with disabilities”.²⁸ One athlete with paraplegia even sought to prove himself to his doctor: “initially, when he had the accident and the doctor informed him that he would never walk again he said ‘that’s okay, I only like to run’”.⁴¹

Teaching and inspiring others

Participants from several studies, ranging from recreational-level to elite-level experience, used sport to teach and inspire others.^28,36,38,41 For example, a rugby player with quadriplegia took advantage of a situation to educate a family: “The whole outlook of the mom and daughter changed as I talked with their dad/husband about being a wheelchair rugby player and the tournament that brought me there”.³⁶ Additionally, a wheelchair racer with paraplegia explained how training on the road was viewed as an inspiration: “the people that go by you are so motivated by what you’re doing  …  they blow their horn”.⁴¹ Other participants expressed a desire to increase awareness of parasport and teach others about the capabilities of people with disabilities.^28,36,41 A 21-year-old rugby player explained, “If there was anything I would want other people to understand [it’s that] we’re just in chairs. Our lives aren’t any different really […] Athletes are athletes”.³⁶

Discussion

The main finding from this study was that sport facilitates the progression to living an enriching life with SCI. Upon initial injury, participants experienced significant disturbances but were able to adjust to SCI with the presence of a positive mindset and supportive social network. Various factors facilitated sport initiation (i.e. pre-injury sport participation), but taking time to come to terms with injury and receiving discouraging messages hindered sport initiation. The extensive benefits of sport included improvements in strength, independence, mental health, and sense of community. Challenges included traveling and finances. Beyond individual outcomes, sport also enabled participants to break stereotypes and re-educate others.

From this qualitative synthesis, it is evident that there are a wide range of physical, psychological, and social benefits of sport participation, which are comparable to the benefits of exercise,^43,44 activity-based therapy,^45,46 and physical activity such as treadmill walking, resistance training, and arm ergometry.⁴⁷ Given the many positive outcomes of sport participation, sport could be encouraged for more people with SCI. Although the exact proportion of individuals with SCI engaging in sport is currently unknown, people with SCI are considered to be among the most sedentary populations^48–50 and several factors that influence sport participation have been recognized in the literature.

Participants from studies in this review expressed how family and friends helped facilitate sport initiation, which was also echoed in other published studies that did not meet the inclusion criteria of our review as they studied differing populations or concepts. Several qualitative studies exploring the perceptions of athletes with a disability on social support highlighted the importance of family and friends in providing financial assistance, encouraging sport participation, and challenging athletes to excel.^51–54 Two of these studies also noted the role of coaches and healthcare professionals as additional types of social support.^52,53 Moreover, the perspectives of parents^55–57 and siblings⁵⁷ on sport participation have been well documented in the literature. Their perceptions are consistent with the benefits of sport reported in this study; for instance, sport helped create a community for athletes, facilitate personal growth, and provide an environment for healthy competition.^55–57 However, this research has primarily focused on the families of children with physical disabilities^55–57 such as spina bifida⁵⁶ and cerebral palsy.^55,56 A future study may consider exploring the perceptions of family members of athletes with SCI.

Logistical challenges to sport were described by participants: the time required to travel, difficulty transporting equipment, and navigating inaccessible buildings. These challenges have also been echoed in the published literature on athletes with physical disabilities.^53,58,59 Of 61 surveyed individuals with SCI who participated in sport, over 90% identified the difficulty of traveling to the sport venue as a barrier.⁵⁹ Lack of accessible toilets and lack of accessible accommodation were also cited as barriers.⁵⁹ Other studies explained that inaccessible sport environments led to a lack of social inclusion among able-bodied peers⁵⁸ and that commuting to sport practices created significant time and distance complications.⁵³ Equipment was also cited as a common barrier.⁵⁸ Knowing these challenges, it is important for athletes and their families to problem-solve collaboratively with coaches to overcome them.

Eleven of the 14 included studies consisted of participants with a mean age under 41 years. This is a noteworthy finding, as the mean age of onset of SCI is increasing;^1,60,61 according to an environmental scan of 13 rehabilitative sites in Canada, the majority of people receiving rehabilitation are over 50 years of age.⁶⁰ Given the demographics of participants in this synthesis, research in sport appears to be missing a large portion of the SCI population. Moreover, the average life expectancy of those with SCI has been increasing,^62,63 meaning more Canadians are aging with SCI and experiencing the associated health challenges.^11,64 Although substantial evidence has been published on the benefits of sport for the aging able-bodied adult,^65–67 there is a paucity of information regarding the use of sport for improving physical, psychological, and social well-being in aging adults with SCI. Therefore, an important direction for future research will focus on investigating the experiences of older individuals with SCI on sport participation.

Limitations

Given the wide range of approaches to conducting thematic syntheses, uncertainty may exist regarding how the synthesis was developed.⁶⁸ To combat this challenge, our study clearly described each step used in the thematic synthesis²³ and followed the ENTREQ guidelines to transparently report synthesis findings.²² Additionally, the exclusion of studies investigating perspectives of other key stakeholders (i.e. coaches, clinicians, family) may have limited the scope of our results. However, focusing on athletes was appropriate for the purpose of this review and will be particularly important for future studies seeking to make effective decisions on program implementation.

Conclusions

This qualitative thematic synthesis described how sport engagement facilitates the progression to living an enriching life with SCI. This synthesis provided detailed insight into the experiences of individuals with SCI who engaged in sport programs. Participants outlined their experiences leading up to the initiation of sport and described the extensive physical, psychological, and social benefits resulting from participation. These findings may be used to provide recommendations for future sport interventions.

Appendix: Search strategy for Medline.

# Search Strategy: Ovid MEDLINE ALL <1946 to January 19, 2021>

1 [Population: SCI & Physically Disabled] 2 exp Spinal Cord Injuries/ (49481) 3 exp Paraplegia/ (13102) 4 exp Quadriplegia/ (8107) 5 Wheelchairs/ (4788) 6 disabled persons/ and (physical* disabled or physical* disabilit* or wheelchair*).tw,kw. (3260) 7 para-athletes/ (24) 8 (spinal cord adj3 (injur* or contusion* or trauma* or transection* or lacerat* or compression* or lesion* or paraly*)).tw,kw. (54340) 9 (paraplegi* or quadriplegi* or tetraplegi*).tw,kw. (24310) 10 (myelopath* adj2 (traumatic or post-traumatic or post traumatic or compressive)).tw,kw. (719) 11 ((spinal cord injur* or SCI) adj3 post*).tw,kw. (1604) 12 ((disabled or disabilit* or handicap* or physically challenged) and (wheelchair* or athlete*)).tw,kw. (2690) 13 (para athlete* or para-athlete* or paralympi* or wheelchair athlete*).tw,kw. (957) 14 (spinal adj3 paraly*).tw,kw. (713) 15 wheelchair*.tw,kw. (7549) 16 or/2-15 (103148) 17 [Concept: Sports] 18 exp sports/ (187691) 19 sports for persons with disabilities/ (214) 20 Sports Medicine/ (10958) 21 Psychology, Sports/ (43) 22 (wheelchair* adj3 (tournament* or basketball or racing or road race* or tennis or curling or rugby or athele* or participat* or participant* or sport*)).tw,kw. (787) 23 (sport* adj4 (community* or competiti* or individual* or participat* or participant* or group* or organiz* or involve* or activ* or team* or club* or adaptiv* or para* or wheelchair* or disabilit* or disabled)).tw,kw. (25961) 24 or/18-23 (208753) 25 16 and 24 (4720) 26 remove duplicates from 25 (4707)

Funding Statement

This research was funded by a grant from the Canadian Institute of Health Research [PJT 153017] to KEM and the Early Researcher Award to KEM.

Conflict of interest

No potential conflict of interest was reported by the author(s).