The feasibility and effect of a peer-facilitated, remote handcycling sport program for aging adults with spinal cord injury or disease: a mixed methods case series

Abstract

Study design

Concurrent mixed methods case series.

Objectives

To examine the feasibility and effect of a peer-facilitated, remote handcycling sport program on physical, psychological, and social health of individuals with spinal cord injury or disease (SCI/D) aged ≥50 years.

Setting

Participants’ homes.

Methods

Manual wheelchair users aged ≥50 years with chronic SCI/D were eligible. Participants completed remote, group-based handcycling at moderate-vigorous intensity twice weekly for 12 weeks, co-led by a physiotherapist and peer with SCI/D. Handcycling duration was progressively increased to 45 min. Outcome measures were completed at three timepoints (pre-, post-, 12 weeks post-training). True change was assessed using the two-standard deviation band method for the Spinal Cord Independence Measure, Moorong Self-Efficacy Scale, Exercise Self-Efficacy Scale (ESES), Positive Affect and Well-Being Scale, and Multidimensional Scale of Perceived Social Support, and minimal detectable change for the 6 min Push Test (6MPT). Semi-structured interviews were analyzed using thematic analysis.

Results

Five participants enrolled; four completed the program and one was withdrawn following fractures unrelated to program. Overall, divergence was observed when comparing quantitative and qualitative findings. Interview data revealed participants perceived physical, psychological, and social health improvements, but there was minimal change in quantitative scores. A few instances of convergence were noted; e.g., immediately post-intervention, SP01 experienced improvement in 6MPT distance, which corroborated SP01’s perceived physical health improvements. At 12-week follow-up, SP03 experienced reduction in ESES score, which aligned with SP03’s reports of skin issues limiting sport.

Conclusions

Remote handcycling provided some health benefits for participants with SCI/D aged ≥50 years.

Introduction

‘Sport’ is a physical activity that involves physical exertion, hand-eye coordination, and/or skill, contains competitive elements, and exists formally through organizations [1]. Participation in sport provides various physical, psychological, and social benefits for individuals living with spinal cord injury or disease (SCI/D) [2, 3]. However, most sport research to date has focused on adults with traumatic SCI who are younger than 50 years of age [2, 3], despite the majority of Canadians with SCI/D being older than 50 years [4] and experiencing increased life expectancy [5].

“Accelerated aging” describes the altered trajectory of aging while living with SCI/D [6]. Various body systems, such as the cardiovascular, musculoskeletal and respiratory systems, are impacted [7]. For instance, aging adults with SCI/D are at higher risk for secondary health conditions including cardiovascular disease, diabetes, bowel or bladder issues, loss of bone mineral density, spasticity, pain, pressure injuries, and shoulder overuse [8, 9]. Moreover, the presence of cardiac complications, high blood pressure, and respiratory complications significantly increases each year with age [10].

Sport participation may be a beneficial activity for individuals aging with SCI/D. While extensive literature supports sport for older adults without SCI/D [11, 12], only one study has captured the perceptions of athletes with SCI/D aged 50 years or older on sport participation [13]. Findings indicated that sport can provide physical, psychological, and social benefits for all people with SCI/D, regardless of age [13]. Aging athletes with SCI/D expressed how sport participation in their later years was more about prioritizing health and preventing injury, rather than maximizing performance [13]. While many of these participants were able to drive, which facilitated participation, a survey on this aging population revealed that one of the top barriers to sport participation was that it was ‘challenging to travel to and from sports activity’ [14]. The barrier of transportation to sport facilities has been well-documented in the literature [15, 16].

Telehealth services such as remote physical activity programs are a strategy that can meet the needs of individuals with SCI/D who experience transportation barriers, while still providing health benefits [17]. For example, home-based telehealth-monitored resistance training with neuromuscular electrical stimulation resulted in increased muscle cross-sectional area [18], and teleexercise involving upper limb ergometry resulted in increased aerobic capacity, physical activity levels, and life satisfaction [19]. A home sports video gaming program was rated as enjoyable for participants and perceived to be an option for engaging in exercise, although it did not produce significant improvements in measured outcomes (e.g., strength, balance, pain) [20]. Adherence in these telehealth programs ranged from 85–100% [18–20]. However, the mean age of participants in the three studies were all under 50 years [18–20], which highlight a critical gap in our understanding on the potential effect of remote sport programs for people with SCI/D aged over 50 years.

The involvement of peers-facilitators can help enhance the experiences of aging people living with chronic conditions who participate in group-based interventions [21, 22]. For instance, the Re-Inventing Yourself after Spinal Cord Injury program was an educationally based group therapeutic intervention that was run for six weeks and led by facilitators with personal and professional experience in SCI/D rehabilitation, which included a peer with SCI/D [22]. Individuals with SCI/D who participated in the facilitator-led learning sessions experienced greater increases in self-efficacy immediately post-intervention, compared to those who did not participate [22]. Moreover, the WheelSee program, which provided six wheelchair training sessions to pairs of individuals living with conditions such as SCI/D, multiple sclerosis, cerebral palsy, was co-administered by a peer with lived manual wheelchair experience and a support trainer [21]. Participants who received this peer-led, group-based intervention experienced statistically significant manual wheelchair use self-efficacy, skills capacity, and performance compared to those who did not receive wheelchair training [21]. Ultimately, peers with lived experience who participate in the design and/or implementation of interventions have been described as being able to enhance credibility of provided information, increase sense of community, and reduce clinician burden [21, 22].

There is a need to examine the role of remote sport participation for addressing the challenges associated with aging and SCI/D. However, there is currently no research to date investigating such a program for aging adults with SCI/D. Therefore, the purpose of this study was to investigate the feasibility and effect of a peer-facilitated, remote handcycling sport program on the physical, psychological, and social health of adults with SCI/D aged 50 years or older.

Methods

Study design

In this concurrent mixed methods case series [23], a single-subject design was followed for the collection of quantitative data [24]. A qualitative descriptive design was selected for the qualitative component [25]. Ethical approval was granted by the University Health Network (UHN) (REB #23-5096) and all methods were performed in accordance with UHN guidelines and regulations. All participants provided verbal and written consent to participate. This study was registered on ClinicalTrials.gov (Identifier: NCT06040749). The Consensus on Exercise Reporting Template (CERT) was followed for describing intervention details [26]. Using an Integrated Knowledge Translation partnership approach [27], a person with lived SCI/D experience was meaningfully involved across various stages of the research process, including conceptualization of the study, implementation of the intervention, and interpretation of study findings.

Participants

Participants were recruited through Spinal Cord Injury Ontario and the Toronto Rehabilitation Institute-Lyndhurst Center. Individuals were eligible to participate in the study if they met the following twelve inclusion criteria: (1) Sustained a traumatic or non-progressive, non-traumatic SCI/D; (2) In the chronic stage of recovery (i.e., ≥12 months post-SCI/D); (3) Aged ≥50 years old; (4) Used a manual wheelchair; (5) Able to understand spoken English; (6) Able to attend two remote handcycling sessions per week for 12 weeks and attend on-site assessments; (7) Did not intend to change usual physical activity routine throughout duration of the intervention; (8) Cleared to participate in exercise (as determined through completion of the 2022 Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) [28] and receipt of physician note indicating medical clearance); (9)Able to secure hands on handlebars with or without assistance during at-home sessions; (10) Had one emergency contact who could be promptly reached at any point during the intervention; (11) Able to independently perform easy-moderate revolutions of arm ergometry movement for ≥10 min, with or without adaptations to secure the hands on the handlebars; and (12) Able to independently bring up at least one hand to wave at shoulder level.

Individuals were excluded if they: (1) Presented with significant shoulder pain that reduced use of upper limbs; (2) Presented with condition(s) other than SCI/D that affect their ability to use the upper limbs or follow English instructions; (3) Had a pressure injury (>grade 2) on the pelvis, sacrum, or hand(s); (4) Experienced major trauma or surgery within the last six months; or (5) Had a history of cardiovascular disease and did not receive physician clearance to participate.

Intervention

This intervention was a group-based handcycling program that was held 60 min twice a week for 12 weeks, the minimum time required for cardiovascular changes to occur [29]. Frequency, duration, intensity, and structure of handcycling were informed by the Fitness Guideline for people with SCI/D [30], qualitative data from aging athletes with SCI/D [13], and interval training sources [31, 32]. Sessions were completed at home, where participants connected remotely on Microsoft Teams (Microsoft Corporation, Redmond, USA), with 2–3 participants per group. Attendance was recorded at each session to track adherence. Due to the group-based nature of the program, participants could not make up missed sessions. Participants were provided with a CanDo Magneciser stationary exercise bike (OrthoCanada, Gatineau, Canada) and Fitbit Charge 5 wristwatch (Fitbit Inc., San Francisco, USA). One participant (SP03) used their own handcycle. To resemble true handcycling, two modifications were applied to the exercise bikes: (1) cranks were repositioned from alternating to in tandem and (2) pedals were replaced such that the hands were repositioned from pronated to neutral (Fig. 1). These modifications further distinguish this sport intervention from stationary arm ergometry programs. A physiotherapist (LC) completed a home visit for each participant to assess safety and set up equipment.

Fig. 1. Set-up of exercise bike in participants’ homes.

Bolded text in this figure signify key features of the exercise bike and italicized text provide additional details.

Each handcycling session began with 15 min maximum of warm-up exercises led by a physiotherapist (LC) (Supplementary Material). Next, handcycling on the exercise bike followed, starting with 15 min and gradually progressing to 45 min. The peer-facilitator (RB) was an international-level competitive handcyclist with SCI/D aged >50 years, who co-led participants alongside LC through interval-based handcycling that reached an intensity of up to moderate-vigorous intensity, which was defined as 80% estimated peak heart rate (HRpeak, calculated as 220 minus age) or standard Borg Rating of Perceived Exertion (RPE) of 17/20 [33]. Depending on their RPE, participants were allowed to adjust resistance and/or handcycling speed to achieve their desired intensity. Zwift, an indoor cycling application (Zwift, Long Beach, USA) was screenshared by the peer-facilitator to provide participants with visual cues and context for guided changes in exercise intensity. To maintain confidentiality of participants’ data, their exercise bikes were not connected to Zwift.

The handcycling intervention followed a periodized program consisting of three four-week mesocycles, which progressively challenged participants in a structured and safe manner (Supplementary Material). To incorporate elements of competition, participants were asked to share their distance cycled at random points throughout the session, which was used to create an informal scoreboard. The partner with lived SCI/D experience (RB) was involved throughout the research process, such as designing the modified exercise bikes, co-developing the periodized handcycling program, contributing to the decision to deliver a remote intervention, educating the research team about Zwift, and implementing the sport program.

Data collection

Feasibility outcomes, which comprised adherence to the intervention and occurrence of adverse events, were collected. Adherence was monitored by taking attendance at the beginning of each handcycling session. Any adverse events that occurred were collected using Limesurvey, an online survey tool (LimeSurvey GmbH, Hamburg, Germany). Existing recommendations and guidelines on adverse event reporting were applied [34–36]. An adverse event was defined as any undesirable outcome, related or unrelated to the intervention, that limited a participant’s ability to participate [37]. Questions about the circumstances surrounding the adverse event were informed by literature exploring adverse event reporting [34, 38] (Supplementary Material).

Clinical assessments were conducted three times at baseline as per single-subject design requirements [24] (except the 6 min Push Test, which was completed once), once immediately post-intervention, and once at 12-week follow-up (Table 1). No specific instructions were provided to participants during the follow-up period. Clinical outcome measures evaluated participants’ physical, psychological, and social health [39]:

Table 1.

Table of events.

DURATION OF PERIOD	6 weeks			12 weeks		12 weeks
ASSESSMENT	Baseline #1	Baseline #2	Baseline #3	Intervention period	Immediately post-intervention	12-week follow-up
LOCATION	MS Teams	MS Teams	On-site visita	MS Teams	On-site visit	On-site visit
TASK
Home visit	X
Demographic Questionnaireb	X
SCIM	X	X	X		X	X
6MPT			X		X	X
MSES	X	X	X		X	X
ESES	X	X	X		X	X
PAWB	X	X	X		X	X
MSPSS	X	X	X		X	X
Exercisesc			X
Activity Log				X
Survey				X
Interviewd						X

SCIM Spinal Cord Independence Measure, 6MPT 6 min Push Test, MSES Moorong Self-Efficacy Scale, ESES Spinal Cord Injury Exercise Self-Efficacy Scale, PAWB Positive Affect and Well-Being Scale of the Quality of Life in Neurological Disorders Measure Short Form, MSPSS Multidimensional Scale of Perceived Social Support, MS Teams Microsoft Teams.

^aOn-site visits were completed at a rehabilitation hospital.

^bDemographic questionnaire queried age, gender, ethnicity, employment status, annual household income range, characteristics pertaining to spinal cord injury or disease, and characteristics pertaining to sport and physical activity.

^cReview of warm-up exercises to be completed during program.

^dCompleted over the phone, over Microsoft Teams, or in-person.

Physical health

1. The Spinal Cord Independence Measure (SCIM) is a valid and reliable questionnaire that evaluates the functional abilities (i.e., self-care, respiration and sphincter management, and mobility) of individuals with SCI/D [40–42]. Total scores for the SCIM range from 0–100, where a higher score indicates greater functional ability [41].

2. The 6 min Push Test (6MPT) assesses aerobic fitness of manual wheelchair users [43, 44]. Participants propelled their wheelchair for 6 min along a 25 m long figure-eight loop [43–45]. Total distance was recorded with a CatEye Cycle Computer mounted onto the wheelchair frame (CatEye Co., Ltd., Osaka, Japan) and using a manual tally of laps. The 6MPT is a valid and reliable measure for assessing aerobic fitness in individuals with paraplegia or tetraplegia [43–46]. Minimal detectable change (MDC) value is 38.18 m for manual wheelchair users with SCI/D [45]. The 6MPT is an efficient and cost-effective method of estimating aerobic fitness, compared to maximal arm ergometry testing [45].

Psychological health

• 3.The Moorong Self-Efficacy Scale (MSES) is a valid and reliable questionnaire that assesses confidence in performing everyday activities for people with SCI/D [47]. Each item is scored on a 7-point scale, for a total score out of 112, with a higher score indicating greater self-efficacy [47, 48].
• 4.The Spinal Cord Injury Exercise Self-Efficacy Scale (ESES) is a valid and reliable questionnaire that assesses confidence in performing physical activities and exercise amongst those with SCI/D [49, 50]. Each statement is scored on a 4-point scale, for a total score out of 40 [49]. A higher score is interpreted as greater perceived exercise self-efficacy [49].
• 5.The Positive Affect and Well-Being Scale of the Quality of Life in Neurological Disorders Measures – Short Form (PAWB) is a short-form questionnaire that assesses affect and sense of well-being [51, 52]. This questionnaire is encompassed within the larger, psychometrically robust PAWB-Neuro-QoL item bank, a tool that assesses health-related quality of life [52].

Social health

• 6.The Multidimensional Scale of Perceived Social Support (MSPSS) is a psychometrically sound questionnaire that evaluates perceived support from a significant other, family, and friends [53, 54]. Each statement is rated from 1 to 7 (“very strongly disagree” to “very strongly agree”) [53].

During each session, participants documented in an activity log their perceived exertion (i.e., determined by Borg RPE Scale ranging from 6–20) and heart rate (i.e., determined by Fitbit wristwatch reading) prior to exercise, mid-exercise, and immediately following exercise.

A semi-structured interview was conducted by NLB, a physiotherapist with qualitative research experience, following completion of the intervention. This interview explored participants’ perspectives on the effect of the program on physical, psychological, and social health. An interview guide (Supplementary Material), informed by the Modified Health through Sport Conceptual Model, was used [3].

Data analysis

All quantitative data were reported descriptively. The two-standard deviation band method was used to assess for change in questionnaires [55]. This method involved calculating the mean and standard deviation of the three baseline measurements for each questionnaire for each participant, computing the position of the bands which were two standard deviations above or below the mean baseline score, and then evaluating where a subsequent score was situated relative to the bands [55]. Scores falling beyond the bands were interpreted as true change [55]. The MDC value was used to assess for clinically relevant change in 6MPT distance [45].

Interviews were digitally recorded and then transcribed verbatim by LC. Thematic analysis was applied to the qualitative data by LC and NLB. Thematic analysis provides a flexible, in-depth exploration of qualitative data and is considered advantageous when working within a participatory research paradigm [56]. Qualitative findings pertaining to the effect of the intervention on health were merged with quantitative results narratively and through a joint display, which enabled the identification of complementary, convergent, and/or divergent findings [57].

Results

After screening 15 individuals, five participants were enrolled. Reasons for exclusion were: unable to attend on-site assessments (n = 2), unable to attend twice weekly remote handcycling for 12 weeks or on-site assessments (n = 3), not in chronic phase of SCI/D (n = 1), not aged ≥50 years (n = 1), pressure injury on the pelvis, sacrum, or hand(s) (n = 2), and condition other than SCI/D that affected use of upper limbs (n = 1). Table 2 summarizes enrolled participants’ demographic and impairment characteristics. Neurological status of participants is reported based on the International Standards for Neurological Classification of Spinal Cord Injury. Participants ranged from 56–64 years of age, and time since SCI/D ranged from 1.4–43 years.

Table 2.

Participant demographic and impairment characteristics.

Participanta	Age range (years)	Gender	Race	Employment status	Time post-SCI/D range (years)	Neurological level of injury	Etiology of injury	Severity of injury (if traumatic)	Presence of Co-morbiditiesb	Pre-SCI/D PA	Current PA	Frequency and duration of PA
SP01	46–60	Man	White	On long-term disability	26–30	L3	Traumatic	Motor incomplete	Yes	Hockey, baseball, soccer, hunting, fishing	Virtual exercise classesc	5–6 days/week 60 min
SP02 (withdrawn after session 14)	61–75	Man	White	On long-term disability	1–5	T9	Atraumatic	N/A	Yes	N/A	Virtual exercise classesc	5–6 days/week 60 min
SP03	61–75	Man	White	Retired	36–40	T4	Traumatic	Sensory incomplete	Yes	Running, soccer, biking, canoeing	Handcycling, flying	1–2 days/week 60–90 min
SP04	46–60	Man	East/ Southeast Asian, White	On long-term disability	1–5	C7	Traumatic	Sensory incomplete	Yes	Cycling, soccer, hockey	Wheelchair basketball, outdoor cycling, gym	3–4 days/week 60–90 min
SP05	46–60	Woman	White	Retired	41–45	T5	Traumatic	Complete	Yes	Cross-country skiing, badminton, gymnastics	Wheelchair curling, squash 57, handcycling	5–6 days/week 90+ min

SCI/D spinal cord injury or disease, PA physical activity.

^aThree participants indicated an annual household income of $100,000 and over. One participant indicated an annual household income of $50,000 to $99,999. One participant preferred not to say. SP01, SP02, and SP03 comprised the first handcycling group. SP04 & SP05 comprised the second handcycling group.

^bParticipants were living with comorbidities including celiac disease, morphea, osteoporosis, high blood pressure, type II diabetes, and high cholesterol. Two participants had a past medical history of cancer.

^cIncluded classes such as high intensity interval training, yoga, aerobics, circuit training, boxing, strength building.

Feasibility outcomes

SP02 was withdrawn prior to study completion due to an adverse event unrelated to the program; a fall resulting in lower limb and vertebral fractures and subsequent hospitalization. An additional six adverse events reported as unrelated to the intervention were encountered: back pain (n = 2), skin breakdown (n = 2), shoulder strain (n = 1), and autonomic dysreflexia (n = 1), which were addressed by suspending handcycling until symptoms improved. The latter was also addressed by ensuring bowels were appropriately managed. The eighth adverse event was a lower back muscle strain from exertion during a handcycling session; this was addressed through rest and stretching. SP01 and SP03 each attended 19/24 sessions (79%), SP04 attended 16/24 sessions (67%), and SP05 attended 21/24 sessions (88%). SP02 attended 13/14 sessions (93%) prior to study withdrawal. Sessions were missed due to vacation, appointments, adverse events, and family matters.

Activity log measures

Heart rate and RPE for the four participants who completed the program are summarized in the Supplementary Material. Three participants reached target exercise intensity at mid-exercise: SP05 reached a median RPE of 17/20, and SP03 and SP04 achieved at least 80% of age predicted HRpeak.

Clinical outcomes

Scores on clinical outcome measures at the three timepoints are outlined in Table 3. Improvement was observed in at least one outcome measure for all participants immediately post-intervention or at 12-week follow-up.

Table 3.

Scores on clinical outcome measures at baseline, immediately post-intervention, and 12-week follow-up.

Shaded boxes indicate values that showed improvement compared to baseline scores.

SCIM Spinal Cord Independence Measure, 6MPT 6 min Push Test, MSES Moorong Self-Efficacy Scale, ESES Spinal Cord Injury Exercise Self-Efficacy Scale, PAWB Positive Affect and Well-Being Scale of the Quality of Life in Neurological Disorders Measure Short Form, MSPSS Multidimensional Scale of Perceived Social Support, SD standard deviation.

^§6MPT was assessed only once at baseline and thus no mean nor standard deviation was calculated.

^*Change greater than 2 standard deviations compared to the mean baseline score that would be considered improvement in performance.

^°Change greater than 2 standard deviations compared to the mean baseline score that would be considered decline in performance.

^{^}Change greater than the minimal detectable change value when compared to baseline.

^†Unable to complete 6MPT at 12-week follow-up due to pain or inability to attend on-site assessment.

Participant perspectives

Following thematic analysis of interview transcripts, two key themes were identified: (1) Remote sport program provided diverse health benefits for aging adults with SCI/D, and (2) Enthusiasm for consistent participation in sport throughout lifetime.

Remote sport program provided diverse health benefits for aging adults with SCI/D. Participants described how their experiences with sport, physical activity, and exercise prior to and after SCI/D led them to have an interest participating in new sport opportunities, such as virtual handcycling. The implemented sport program was reported to have various effects on participants’ physical, psychological, and social health (Supplementary Material), with several perceptions specific to aging. Physical benefits included “muscle growth” (SP01), “[getting] the blood moving” (SP03), and “build[ing] up some strength in my arms” (SP04). SP01 described how his initial belief about muscle growth at his older age was debunked: “once you hit your 60, you don’t think you can gain muscle again […] I’m going, ‘well that just blew that theory out of the water’”. Psychological benefits of the remote sport program included being a “good mental challenge” (SP01), “reinforc[ing] a positive self-image” (SP03), providing “a sense of accomplishment” (SP04), and providing “a distraction from all of that [life challenges]” (SP05). The program was also described as helping SP03 mitigate the “self-reflection and criticism” surrounding his concerns about aging. The social, group-based nature was particularly appreciated by participants: the program provided “a higher level of accountability” (SP05) to exercise consistently, competition to “spur you on” (SP01), and feelings of “support by the group” (SP04). The remote program also provided the opportunity to “meet new people with shared experiences” (SP01) and “interact with people that have similar energies as I did” (SP04). Overall, participants expressed a desire for the program to have run longer to optimize health benefits: “I wish it went longer than 12 weeks” (SP01).

Enthusiasm for consistent participation in sport throughout lifetime. Participants were enthusiastic to sustain the “regularity” (SP03) of sport and physical activity following completion of the remote sport program: “100% in favour of it” (SP03) and “it’s so important” (SP01) (Supplementary Material). The health benefits and learnings gained provided motivation to continue participating: “I’m going to keep going with the bicycling, for sure” (SP01). Specifically, participants were interested in retaining elements of the sport intervention in their routines going forward, and acknowledged that being consistent in participation was critical in sustaining their health as they aged with SCI/D. SP01 described a desire to purchase a bike to cycle with his spouse: “Go[ing] for a bike ride with my wife would be really nice, after 29 years of not being able to”, and SP03 wanted to maintain the same regularity of sport sessions: “I understand […] how important it is to be repetitive and regular in aerobic activity”. SP04 also shared his commitment to handcycling to maintain cardiorespiratory fitness: “The handcycling […] I am continuing to do that […] to help build up my cardio”. However, several participants described challenges that limited sport participation, such as managing “skin issues” (SP03), “facing more surgery” (SP01) due to neck pain, and dealing with “cancer treatment” (SP05). Despite the challenges experienced, SP05 emphasized the need to focus on living a healthy lifestyle: “the only way to be less worried about [cancer] is to be busy, to be active, to be exercising, to be eating well, and just like living as well as you can […] you know, focusing on your health and not sort of dwelling on it […] it’s something you have to live with”.

Comparison and integration of quantitative and qualitative data

A joint display of quantitative and qualitative findings is depicted in Table 4. Overall, health domains primarily demonstrated divergence; qualitative findings indicated numerous perceived health improvements from the program, but most clinical outcome measures revealed no change in scores. Interestingly, interview data revealed that SP03 experienced skin issues limiting sport participation during the follow-up period, which was corroborated by reduction in ESES score.

Table 4.

Joint display of quantitative and qualitative findings.

		Physical health			Psychological health				Social health
		SCIM	6MPT	Qualitative	MSES	ESES	PAWB	Qualitative	MSPSS	Qualitative
SP01	Immediately post-intervention	O	+	+	O	O	O	+	O	+
	12-week follow-up	O	N/A		O	O	O		O
SP03	Immediately post-intervention	O	O	+	O	+	O	+	+	O
	12-week follow-up	O	O		O	–	O		O
SP04	Immediately post-intervention	–	O	+	O	O	+	+	O	+
	12-week follow-up	–	N/A		O	O	+		O
SP05	Immediately post-intervention	O	O	+	O	O	O	+	O	+
	12-week follow-up	O	N/A		O	O	+		O

SCIM Spinal Cord Independence Measure, 6MPT 6 min Push Test, MSES Moorong Self-Efficacy Scale, ESES Spinal Cord Injury Exercise Self-Efficacy Scale, PAWB Positive Affect and Well-Being Scale of the Quality of Life in Neurological Disorders Measure Short Form, MSPSS Multidimensional Scale of Perceived Social Support, N/A Not Applicable.

+= improvement.

O = no change.

– = reduction.

Discussion

This study was the first sport program designed to target adults with SCI/D aged 50 years or older. All participants experienced improvement, based on the two-standard deviation band method or the MDC value, in at least one outcome measure immediately post-intervention or at 12-week follow-up. A total of eight adverse events were documented; one was a serious adverse event unrelated to the intervention. Adherence to the scheduled sessions of the intervention ranged from 67–88% for the four participants who completed the program.

Improvement was observed in only 1–2 outcome measures for each participant, despite many diverse health benefits being reported during the interview. One reason may be due to the ceiling effects observed in measures such as the MSES, ESES, and MSPSS. Through the two-standard deviation band method [55], if a participant received high scores on an outcome measure at baseline, it was at times not possible for improvement to be experienced in that measure at subsequent timepoints. A factor contributing to high baseline scores pertains to participants’ strong physical activity backgrounds, as literature shows that physical activity and exercise provides many health benefits [33, 58]. Since all participants were already involved in physical activity at the time of the intervention, the addition of this program led to minimal opportunity for health improvement, highlighting the need to develop low entry sport interventions to encourage the participation of less active individuals. Although our measures were selected based on the common data elements for SCI/D [39], use of more performance-based measures in addition to patient-reported outcome measures may be appropriate for future sport studies. Moreover, given that psychological health such as self-efficacy may fluctuate overtime, it is recommended for psychological outcomes to be assessed at shorter increments post-intervention, such as every 4–5 weeks [59].

Heart rate was not a strong indicator of exercise intensity for aging adults with SCI/D. For instance, SP05 was only able to achieve an average heart rate of 67% of age predicted HRpeak mid-exercise, despite cycling at a median RPE of 17/20. This difficulty in attaining sufficient cardiovascular load was likely influenced by autonomic dysfunction. People with SCI/D have reduced heart rate variability and impaired heart rate recovery with exercise compared to non-SCI/D controls, which is indicative of decreased autonomic cardiac modulation [60, 61]. Due to impaired autonomic cardiac modulation, research has demonstrated HRpeak values for adults with SCI/D that are much lower than estimated HRpeak calculations [61, 62]. Instead, use of RPE [63] or a talk test [64] may be more useful indicators of exercise intensity for individuals with SCI/D [65].

Qualitative data indicated that participants wished to continue handcycling during the follow-up period, but challenges with skin breakdown, pain, and comorbidities limited participation. While these challenges did not result from the intervention, which is in line with the literature [66], they indeed negatively affected exercise adherence and the follow-up assessments. Although adherence was comparable to other arm crank exercise interventions [66, 67], the group-based and competitive elements of this sport intervention may have had larger implications on missed sessions compared to exercise programs alone: “You don’t want to let them down” [68]. Moreover, research has shown that aging with SCI/D is associated with increases in secondary health conditions such as pain, pressure injuries, and cardiac complications [8–10]. Heightened awareness of these complications has also been reflected by athletes with SCI/D aged 50 years or older, who reported a need to perform constant skin checks to avoid development of pressure injuries [13]. Indeed, applying an inter-disciplinary approach and referring to clinical practice guidelines [69] is critical to ensure safe adherence to sport for this population. To gain more comprehensive understanding of how health complications impact exercise adherence, future sport studies should monitor adverse events during the follow-up period as well [70].

Limitations

The small sample sizes of single-subject designs prevent generalizability of findings [71]. As such, we are not able to draw conclusions on the effect of sport for aging adults with SCI/D. However, given the limited research investigating sport participation for this population, the findings from this work can justify further exploration of this area through larger studies such as randomized controlled trials employing a larger sample size and more rigorous analysis approach. Secondly, heart rate was used as an indicator of exercise intensity, although research suggests that this method is not a reliable measure for use with those living with SCI/D [72, 73]. The age-predicted maximal heart rate equation used in this study was catered towards the general population rather than more focused groups such as wheelchair athletes who complete upper limb exercise [74] or adults aged over 40 years [75]. Such equations have a large prediction error (i.e., confidence intervals of approximately ±24 beats per minute) [76]. Thus, inaccuracies in heart rate calculations and measurements may have influenced interpretation of study data [72, 73, 76]. Lastly, Fitbit wristwatches were used for measuring heart rate, which are known for providing inaccurate heart rate readings when used with people with SCI/D compared to those without [77]. Future studies may consider using a chest strap to monitor heart rate more accurately in exercising individuals [78].

Conclusions

Improvements in health were observed in all participants on at least one clinical outcome measure immediately post-intervention or at 12-week follow-up. Interview data revealed that participants perceived diverse physical, psychological, and social health effects from the intervention, and were interested in sustaining sport participation in the future.

Author contributions

LC contributed to study conceptualization, participant recruitment, program implementation, data collection, data analysis, and writing of the manuscript. RB contributed to study conceptualization, participant recruitment, program implementation, and manuscript revision. NLB contributed to data collection, data analysis, and manuscript revision. CA contributed to participant recruitment and manuscript revision. SM contributed to study conceptualization and manuscript revision. BCC contributed to study conceptualization, participant recruitment, and manuscript revision. KEM contributed to study conceptualization, project supervision, and manuscript revision. All authors have reviewed and agreed to the final version of the manuscript.

Funding

This work was funded by the Diane Gasner Graduate Scholarship to LC and the Shelagh Walsh Research Fund to KEM.

Data availability

Additional data are available from the corresponding author upon reasonable request.

Competing interests

The authors declare no competing interests.

Supplementary information

The online version contains supplementary material available at 10.1038/s41394-025-00721-1.