Beyond rehabilitation: a qualitative exploration of sport participation context and FES-cycling user experience in spinal cord injury

Abstract

Background

While functional electrical stimulation (FES)-cycling benefits for spinal cord injury (SCI) are documented, user acceptance and sustained engagement remain underexplored. Understanding how sport participation history and values shape FES-cycling experiences is essential for predicting technology adoption beyond rehabilitation.

Objective

To explore FES-cycling user experiences within the context of participants’ sport participation history, examining how sport-related values, post-injury adaptations, and existing barriers influence device acceptance and attitudes towards sustained use.

Methods

Fifteen male individuals with SCI (mean age 43.9 ± 14.0 years; mean time since injury 11.2 ± 11.9 years) participated in the study, with 11 presenting complete and four incomplete SCI. They all completed a short FES-cycling training and semi-structured interviews exploring: sport experiences pre/post-injury, disability impact on participation, barriers and facilitators to sport access, FES-cycling user experience and future use perspectives. An inductive thematic analysis identified patterns across data, adopting a data-driven approach through line-by-line coding to identify emergent themes, subsequently organized within a higher-order thematic framework.

Results

Five themes emerged: (1) meanings attached to sport (competition, cooperation, escape, resilience, self-improvement); (2) post-injury sport changes (physical/psychological adaptations, renewed appreciation); (3) sport access (barriers: cost, infrastructure, time; facilitators: organizations, policies); (4) FES-cycling experience (physical/emotional benefits, frustrations); and (5) future perspectives (opportunities, limitations).

Conclusions

Sport-related values directly shaped how participants evaluated FES-cycling capabilities and practical viability. FES-cycling acceptance depends on whether the device aligns with users’ sport-related values and addresses their existing barriers to participation. Realistic implementation, supported by dialogue with participants about limitations and challenges, can help bridge the gap between rehabilitation and sustained engagement in physical activity.

Background

Spinal cord injury (SCI) refers to complete or incomplete damage to the spinal cord resulting from physical trauma (e.g. falls or road traffic injuries) or non-traumatic causes (e.g. tumours, degenerative conditions, infections) [1] leading to temporary or permanent changes in sensory, motor and autonomic function, including partial or complete loss of motor function below the level of injury. Individuals with a SCI also encounter several psychosocial challenges [2], which include high risk for depression, social isolation, unemployment and reduced community participation, influencing overall wellbeing [3]. These multidimensional challenges posed by SCI recommend an integrated approach to develop proper patient rehabilitation [4].

Regular participation in exercise and physical activity represents a valid way to enhance health outcomes, by improving the physiological functioning and fitness status, as well as the subjective well-being and overall quality of life [5]. International PA guidelines recommend regular moderate-to-vigorous aerobic and strength exercises for persons with SCI [6], which should extend beyond clinical settings [7].

Sport is a structured and often competitive form of physical activity that aims to maintain or improve physical abilities and skills. Beyond its physical benefits, it holds strong potential as a holistic intervention for addressing the physical, psychological and social health domains [8]. Sport-based rehabilitation for individuals with physical disabilities, established since World War II [9], improves quality of life and life satisfaction [10], enhancing rehabilitation outcomes and fostering competitive events that combine exercise with sport [11,12]. It may incorporate a range of adapted sport, with swimming, wheelchair basketball, table tennis and adaptive cycling, including hand cycling, among the most frequent.

Understanding how individuals with SCI relate to sport, both before and after injury, provides critical insights into their motivations, barriers and expectations regarding future physical activity pathways. After SCI, sport participation decreases significantly [13], despite the established benefits for preventing secondary complications [14], and improving cardiorespiratory fitness, social interaction and life expectancy [15,16]. While the benefits of PA and sports participation among individuals with SCI are documented, individuals still face barriers to participation, reflected in persistently low engagement rates [17].

The meanings individuals attach to sport can profoundly influence their engagement with PA programs. Sport participation holds multiple meanings for individuals – from competition and achievement to social connection and personal resilience [18] – which evolve after injury and shape engagement with PA programs. These meanings do not disappear after injury; rather, they evolve and adapt, shaping how individuals approach new forms of physical activity. Understanding these evolving meanings is essential when using technologies for the first time, as they provide a framework for understanding user expectations, potential frustrations and sources of motivation.

Several barriers have also been identified that hinder participation in sports and PA, such as financial constraints, lack of opportunities and need for support [15]. Among the studies that investigated sport and physical activities in SCI, previous qualitative research has documented the importance of sport and leisure for community integration and facilitating life with SCI [19,20].

Understanding these barriers in the broader context of sport participation is crucial when introducing specialized technologies such as FES-cycling, where functional electrical stimulation (FES) is used via surface electrodes to generate muscle contractions that enable active pedalling in individuals with SCI [21,22]. In the rehabilitation context, a recent systematic review reported the use of FES-cycling in 97 studies [14], with evidence showing benefits in neurological and functional performance, increased muscle size and force-generation, reduced spasticity, and improved quality of life. Further reported benefits include improved oxygen consumption during exercise [23], and quality of life in individuals with chronic SCI [24].

Existing perspectives on FES-cycling programmes involve experienced therapists, rather than the actual users, to identify the facilitators and barriers to participation [23] prioritizing physical outcomes while overlooking potential psychological benefits and the broader context of sport participation.

What remains unexplored is how individuals’ sport histories, their evolving relationship with physical activity post-injury, and the barriers they face in accessing sport might influence their experience with and acceptance of FES-cycling technology. Understanding whether and how FES-cycling aligns with users’ sport-related values, motivations and expectations is essential because, without this contextual understanding, FES-cycling would be evaluated only on technical performance, overlooking the psychosocial dimensions that ultimately determine whether users will integrate these devices into their lives beyond rehabilitation settings.

Specifically, this study investigates the relationship between individuals’ sport participation history – including pre-injury engagement, the impact of disability, and current barriers and facilitators to adapted sports – and their experience of FES-cycling, including its physical and emotional sensations, perceived benefits, frustrations and implications for future use.

This integrated perspective addresses a significant gap in the literature: while previous studies have examined either sport participation experiences [19,20] or FES intervention outcomes [23,24], none have systematically explored how the former shapes the latter. Understanding this relationship could be useful in fine-tuning FES-cycling devices to better suit individual requirements, understanding the psychosocial factors that influence acceptance and sustained use, and ensuring these devices are viable tools for physical activity programs and sports usage beyond the controlled rehabilitation setting.

Methods

This work was conducted as part of a prospective study investigating the usability, acceptability, user-experience and human–device interaction of two FES-cycling devices: a FES-Bike (FB) recumbent prototype, and the commercial BerkelBike Pro for individuals with SCI [24]. Approval for the research protocol was granted by the Ethics Committee of IRCCS E. Medea – Sezione Scientifica Associazione La Nostra Famiglia (Prot. N.14/22 – CE, 31 May 2022), and all procedures adhered to the Declaration of Helsinki. Written informed consent was obtained from participants prior to data collection. All efforts to anonymize individual qualitative data were taken to protect participants’ confidentiality, including the use of pseudonyms and the removal or alteration of specific identifying details. Written informed consent to publish the data was obtained from all individual participants. The study’s reporting complies with the Standards for Reporting Qualitative Research (SRQR) (see Supplementary Materials S3).

Study design

This study employed a qualitative design. According to guidance by Braun and Clarke [25], an inductive thematic analysis using semi-structured interviews was performed [23]. This qualitative method represents a flexible approach to identify patterns across the data, via reading multiple times the interviews and retrieving related themes [26] without having any particular conceptual framework [23]. While themes emerged inductively from the data [26], the interview structure was designed to capture both sport participation and FES-cycling experience, recognizing that these domains are interconnected in users’ lived experiences and decision-making processes regarding assistive technology adoption.

Participants

From July 2022 to October 2023, 15 participants were recruited from the Valduce Hospital – Villa Beretta Rehabilitation Center (Costa Masnaga, Italy) and the INAIL network (Istituto Nazionale Assicurazione contro gli Infortuni sul Lavoro, Italian Institute for Insurance against Accidents at Work). At Villa Beretta, a medical team was responsible for participant recruitment and for performing the clinical assessments required to determine eligibility and establish participants’ clinical status [24]. After signing the informed consent, participants were involved in the study. Inclusion criteria were:

• Age between 18 and 65 years.

• Complete or incomplete SCI (injury level ≤ T3).

• Ability to achieve visible muscle contraction through electrical stimulation.

• Control over the trunk sufficient to independently grasp the handlebars and steer effectively.

• Absence of a level of spasticity preventing device use and of disabling pain during training.

• No skin lesions in the interface areas with the device.

Exclusion criteria were:

• Severe osteoporosis.

• Dysfunction of the autonomic nervous system that could negatively affect training.

• Presence of psychopathological comorbidities (e.g. severe depression and/or anxiety) that may hinder the study participation.

Devices and sessions

Participants were asked to test two FES-cycling devices (Figure 1(A)). The first device is a FB prototype developed by Politecnico di Milano, based on a commercial recumbent trike (ICE VTX, 2017, Falmouth, UK), adapted for FES-cycling for individuals with reduced mobility [27]. The second device is the commercial BerkelBike Pro (BB, BerkelBike BV, Sint-Michielsgestel, The Netherlands), a recumbent bike (Figure 1(B)) integrating arm and leg movements through a chain mechanism to propel the bike forward and FES.

Figure 1.

Devices used during the training. (A) Prototype developed by the researchers of Politecnico di Milano. The image has been developed with BioRender software – https://www.biorender.com/. (B) The commercial BerkelBike Pro.

The two devices are suitable for indoor and outdoor training, although the FB, lacking combined arm and leg propulsion, limits its outdoor use unless preceded by a preparatory phase [24]. Participants tested both cycling devices in a randomized and counterbalanced sequence in a controlled laboratory setting, to maintain consistency in testing conditions.

All participants included in the study visited the IRCCS E. Medea (Bosisio Parini, Italy) and tested each device in three indoor sessions lasting between 60 and 90 min each, including montage and FES-cycling training (refer to [24] for further details).

Interview guide and data collection procedure

A semi-structured interview was designed by a psychologist with questions aimed at investigating how individuals with SCI approached sports before and after the lesion (Section 1, Supplementary material), the impact of disability on their experience of sports (Section 2, Supplementary material), their experience with the tested bikes (Section 3, Supplementary material), and their perspectives on the future use of FES-cycling devices (Section 4, Supplementary material). The interview guide (available as Supplementary material S1) was developed according to Graham et al. [28] and tested with an individual with SCI who was not part of the final sample. The interview guide was structured to first establish participants’ sport participation history and current barriers/facilitators (Sections 1 and 2, Supplementary material) before exploring FES-cycling experience (Sections 3 and 4, Supplementary material). This design allows to interpret participants’ responses to FES-cycling through the lens of their sport-related values, motivations and existing participation constraints, rather than evaluating the technology in isolation from users’ broader physical activity contexts.

A semi-structured interview was conducted at the end of the third session for each device, resulting in two interviews per participant. Sections 1 and 2 (Supplementary material) of the guide, which explore participants’ background in sports and the impact of the injury on their experience, were administered only during the first interview, as this information remained constant across both devices. In contrast, Sections 3 and 4 (Supplementary material), which focus on participants’ experience with each bike and their views on the future use of FES-cycling, were administered after both sessions to capture device-specific feedback. Thus, although data collection was distributed across two experimental sessions to accommodate the testing of the two FES-cycling systems, it was conceived as a single semi-structured interview, with the second session representing the continuation of the same interview rather than an independent data collection event. Interviews were administered by two researchers (RN, EB) with a technical background and previous experience with focus groups. To ensure continuity throughout the process, each participant was interviewed by the same researcher across both sessions, allowing follow-up and probing questions to build upon topics that had emerged previously when appropriate. The researchers held several alignment meetings with a psychologist (MCh), to discuss both the interview guide content and the administration procedures. All interviews were conducted face-to-face and audio-recorded.

Data analysis

Interviews were transcribed verbatim by four psychologists and coded using Microsoft Excel (Redmond, WA). An initial round of coding was performed by the same group of psychologists, working separately on a selected sample of four interviews. According to the coding procedure, the researchers went through the text line-by-line identifying recurrent themes and labelling them. A scheme of codes and sub-codes was produced, and a series of group meetings were organized to discuss each researcher’s output, addressing the dissimilarities and aligning the labels to obtain a uniform analysis. This was an iterative process and, according to an inductive approach, depended on each investigator’s interpretation rather than on an existing theoretical framework [29]. Thematic saturation [30] was reached when no new codes or themes emerged from further interviews. Using an iterative process of data collection and constant comparative analysis, we observed recurring themes by the 12th interview, with no new codes identified. To ensure robustness, three more interviews were conducted (n = 15 total). A final revision of all coded interviews was performed by MCh. A senior researcher with expertise in qualitative methodology (SB) supervised the whole process of analysis and the common schema of codes and sub-codes. Finally, a group meeting with all co-authors was organized, aimed at combining the codes into high-order themes.

Results

Participants

A total of 30 interviews were conducted on 15 male participants with SCI, who tested the two FES-cycling devices. One interview was not recorded due to technical problems, and hence not included in the overall analysis (n = 29). Participants were all above the legal age, with a median age of 50 years. Eleven individuals had a complete lesion of motor tracts according to the American Spinal Injury Association Impairment Scale [31] (ASIA A and B) and four an incomplete SCI (ASIA C and D), seven had an injury less than 5 years ago, while eight sustained an injury more than 5 years ago, with an overall median time after SCI of 5.5 years. More demographic details are reported in Table 1.

Table 1.

Demographic data, previous experience with sport and previous experience with FES and cycling devices.

ID	Age (years)	Time after SCI (years)	ASIA grade	Previous experience with FES	Previous sport experience before SCI	Previous experience with cycling after SCI
S01	50	3.8	D	Yes	Occasional/unstructured activity	No
S02	64	2.1	A	Yes	Competitive/intense activity	No
S03	57	24.2	C	Yes	Occasional/unstructured activity	Yes (cyclette)
S04	35	0.7	A	No	Competitive/intense activity	No
S05	52	31.3	A	No	Amateur/structured activity	No
S06	58	12.8	A	No	Amateur/structured activity	No
S07	20	6.2	C	Yes	Amateur/structured activity	No
S08	50	12.0	B	No	No sports activity	No
S09	29	5.5	A	No	Occasional/unstructured activity	Yes (handbike)
S10	49	28.8	C	Yes	Competitive/intense activity	No
S11	51	32.5	A	No	Occasional/unstructured activity	No
S12	23	1.8	A	No	Amateur/structured activity	No
S13	27	1.6	B	Yes	Amateur/structured activity	Yes
S14	29	1.1	A	Yes	Amateur/structured activity	No
S15	65	3.0	A	No	Amateur/structured activity	Yes (handbike)

ASIA: American Spinal Injury Association Impairment Scale.

Themes and subthemes

The inductive thematic analysis led to the identification of five themes and 11 subthemes. Further details on the associated codes are reported in Table S2 (Supplementary material S2). Five main themes emerged from the analysis. The first concerned Meanings attached to sports, encompassing meanings associated with self-improvement and with the presence of others. The second theme, The day after: how sport changes, captured changes in physical abilities and personal attitudes. The analysis then explored Access to sports, focusing on facilitators and barriers to participation. Participants’ experiences with FES-cycling were captured in the fourth theme, FES-cycling: lived experience, which encompassed frustration, positive experiences and perceived benefits of using the bike. Finally, FES-cycling: future perspectives addressed participants’ views on opportunities and limitations.

Theme I. Meanings attached to sports

Within this theme, we outline the meaning attributed to sport activities by the participants, organizing their responses into two subthemes: those related to personal self-improvement and those driven more by social and community-related motivation [18].

Ia. Meanings associated to self-improvement

Within this subtheme, the following codes were grouped: ‘Sport as an escape’, ‘Sport as balance’, ‘Sport: resource for building resilience’ and ‘Sport as a stimulus for self-improvement’.

Beyond enjoyment and sense of escape, the need for balance in life is an important factor that individuals characterized by SCI seek; sports can represent an enabling resource for them, meaning the opportunity to be engaged in activities that are not just fun but stable, no matter what is happening in their life at that moment.

So since in that situation one gets, how to say, the balance that one has in his daily life and everything is totally … how to say disrupted, is shifted …, post trauma one tries to somehow regain a balance, a balance …, that allows him to move forward, right? And in my opinion, sport, sports activity, is a necessary activity to regain. (S01, incomplete SCI, 3.8 years after SCI)

Sport is also considered as a resource to prevent physical decline and to limit hospitalization, enabling psychological empowerment. Participants also highlighted the need to get satisfaction from the competitions and/or from constant practice.

Practising sports is for me to feel normal, I don’t consider myself handicapped or disabled, I am in certain situations but still I see that for most of the let’s say normal activities what a person can do from standing, I can also do from sitting with proper precautions. (S15, complete SCI, 3 years after SCI)

Ib. Meanings associated to the presence of others

Within this subtheme, the codes ‘Sport as competition’ and ‘Sport as cooperation’ were grouped.

Competitive aspects embedded in sports are indicated by participants as an important reason for its practice: being involved in competitions, confronting with peers stimulates the exercise. Also, the cooperative aspect of sport, with the intent to share resources and experiences was mentioned by the participants.

I had much more desire to compete with friends, well … I liked it because of that …. I never had the ambition to do a particular sport, mostly because I found it more fun, that is, everything related to friendship. (S14, complete SCI, 1.1 years after SCI)

Theme II. The day after: how the sport changes

The second theme was related to how the sport experience has evolved because of the SCI injury, specifying the changes in physical abilities and personal attitudes.

IIa. Changes in physical abilities

Two codes were related to this subtheme: ‘Autonomy after the injury’ and ‘Pre-post injury physical ability comparison’.

The consequences of a SCI can be varied: autonomy in everyday life is highly impacted, and the need for assistance becomes a key aspect.

Well, I still have to get used to some things a little bit … for example, whenever somebody wants to push me and there are other people around, it can bother me just to have somebody to help me, right? (S04, complete SCI, 0.7 years after SCI)

Despite an initial phase of frustration due to difficulties in adapting to previous sport practices, the desire to engage in sports remains.

I honestly am in love with basketball and it did not make any difference to me that it was either wheelchair or standing. (S07, incomplete SCI, 6.2 years after SCI)

IIb. Changes in personal attitudes

Within this subtheme, four codes were grouped: ‘Appreciation for sport post-injury’, ‘Motivation to play sport post injury’, ‘Suffering caused by the injury’ and ‘Emerging of resources post injury’.

The likelihood to play sports is reported by participants, describing a renewed approach to sports that were never tried before and becoming valued.

In the early days … I used to struggle a little bit … But over time, over the years, I mean … let’s say in the beginning I did the arm ergometer to experience fatigue, that gave me satisfaction, however, I didn’t appreciate the sport … the way I appreciated it before. And lately instead I appreciated it more, with canoeing…. (S05, complete, 31.3 years after SCI)

Although demanding, the SCI can promote the onset of unexpected personal resources that can be employed towards sports, in a virtuous circle that in turn improves self-esteem.

When something like that happens, … it’s like we have a lot of resources, hidden resources that come out in extreme conditions. (S01, incomplete, 3.8 years after SCI)

Theme III. Access to sports

The third major theme revolves around facilitators and barriers that might enable or hinder the enrolment in a sport.

IIIa. Facilitators

Facilitators entail ‘Social protection and welfare’ and ‘voluntary sport organisations’ codes. The first are regulated by national policies, the latter by private initiatives, both providing support to individuals with SCI.

Luckily, there are also individuals, organisations, who are able to guarantee you a sports. (S01, incomplete, 3.8 years after SCI)

IIIb. Barriers

Barriers to sport access included the following codes: ‘Costs’, ‘Architectural barriers’, ‘Time’ and ‘Local initiatives’. Among the barriers to access sports, participants mentioned costs, especially those for highly specialized and sport-specific equipment necessary for its practice and not covered by welfare policies. Architectural barriers also represent a pervasive limitation in daily life activities of individuals with serious limitations in mobility. Another reported limitation to sport accessibility is time: especially when it comes to disability, the everyday activities might be time-consuming and little time can be devoted to the practice of sports. The presence of local associations and community-based initiatives remains limited; however, where available, they represent a valuable resource for overcoming some of the barriers outlined above.

It is very expensive, and having an association that allows you to try it for free at the various ski resorts would be better; so, actually those who can afford it go, those who can’t afford it don’t, because it will cost 3/4000 euros that equipment. (S04, complete, 0.7 years after SCI)

Theme IV. FES-cycling: lived experience

Participants described the experience with FES-cycling, indicating negative and positive feedback about the tested FES-cycling devices.

IVa. Frustration

Negative experiences mainly stemmed from frustration due to unmet expectations, related both to participants’ performance, when tasks proved more demanding than expected, and to concerns about the suitability of the cycling devices for everyday use.

So, well, I have to say that I had already tried FES, cycling, and various other things… umm […] but it’s still something that isn’t quite there yet—like the exoskeleton, it’s not fluid enough yet to say: “yeah, it’s good to use, I can walk around with it”. So I kind of built up this … let’s face it, disappointment about the machines because I know they’re maybe already a way but I know they’re still …. (S13, complete, 1.6 years after SCI)

IVb. Positive experiences

The positive experience of FES-cycling was a result of the ‘Impact from device use’, the ‘Distinctive benefit not given by other experiences and/or aids’ and ‘Well-being derived from participation in the study’. Overall, the participants reported positive feelings, pleasantness and satisfaction, even if indicating that sometimes it may take time to accept the technology.

It surprised me, because I didn’t expect it … to be able … how to say … although … for … short distances, ehhm … to be able to activate … how to say, to move my legs. (S01, incomplete, 3.8 years after SCI)

IVc. Benefits of using the bike

The perceived benefits of using the bike are grouped in this sub-theme, ranging from physical to emotional aspects. Training for the lower limbs was highly appreciated because often not covered by the majority of sport disciplines for individuals with SCI.

I had a benefit … from this thing … definitely … […] … moving the legs… stimulating them […] that’s a benefit… I mean, anyway mmhh… rather than keeping them still. (S01, incomplete, 3.8 years after SCI)

Regarding emotional aspects, participants reported a positive impact of the bike on mood. Using the bike stimulated bodily sensations, triggering self-efficacy and desired autonomy.

I will tell you the first, the first feeling was, in my opinion, the best. When I was pedalling and I could feel the fatigue, a kind of heated, quickened pulse, a kind of physical activity that, a year after the accident, not feeling it anymore, … feeling it again gave me the … yes yes that you can still do everything. (S14, complete, 1.1 years after SCI)

Theme V. FES-cycling: future perspectives

The last theme emerged from the interviews is about the future perspectives envisioned by participants. The results were grouped in opportunities and limits, to discuss FES-cycling use in the future.

Va. Opportunities

Among the opportunities coming from the FES-cycling devices, several ‘Social opportunities’ are reported: social life could improve by practising sport with peers who share similar conditions and meeting new people without disabilities. Using FES-cycling was also seen as a potential opportunity to engage in sports, including outdoor activities.

The sport whether one … has … an injury … or not … you … socialise anyway … so … it gives you the opportunity to move … to other places … to meet other people, in this case if you do competitive sports … you meet other people … from other regions … other cities …. (S03, incomplete, 24.2 years after SCI)

Vb. Limits

The limits of the potential future use of the FES-cycling device are varied. One limitation relates to the geographical area in which users live. Participants also reported difficulties in setting up the device and a general sense of insecurity during use. In addition, a limited sense of independence emerged, as electrodes self-placement and the transfer from the wheelchair to the bike were perceived as potential barriers.

You can’t go everywhere with a bike like that, that’s the problem. (S08, complete, 12 years after SCI)

‘Fatigue’ and ‘Pain’ are also discussed as potential limits to FES-cycling future use. Pain emerged as a limiting factor, even for individuals with complete lesions who may fear unperceived physical damage. Limits associated with the electrostimulation were also reported: the short battery life affecting the outdoor use, and the discomfort during its use.

… then I enjoyed using it however I wouldn’t use it outside of this experience … mainly because I mean, here I didn’t get too tired but I’m assuming maybe on the road it might be a little more challenging than that. (S07, incomplete, 6.2 years after SCI)

Discussion

This qualitative study explored how individuals with SCI experience FES-cycling technology within the broader context of their sport participation history and evolving relationship with physical activity. This integrated approach reveals how sport-related values, motivations and current participation constraints shape both immediate user experience with FES-cycling and attitudes towards its potential role in sustained physical activity engagement beyond rehabilitation settings.

Participants reported various meanings attributed to sports before the injury: some associated sport practice with competition, others with cooperation with peers. This aligns with the opportunities that sports can offer to individuals with SCI [20]. Other respondents described sport as an escape, highlighting its role in creating dedicated leisure moments within the weekly routine and preventing potential negative mind-wandering about the impairments caused by the injury. This corroborates with previous research discussing the possibility for individuals with SCI to use sport as a means to keep the mind occupied [20].

Sport is also used to improve resilience and to promote self-improvement. Practising sport could be an opportunity to cope with the limitations linked with SCI conditions, by experiencing physical and psychological resources that might have been locked away. Individuals reported that practising sport can re-establish a sense of normality [32], offering the opportunity to set and pursue goals to achieve. This paradigm adopts a ‘strength-based’ approach, focusing on exploring and enhancing resources, as opposed to a ‘deficit-based’ model, which examines the weaknesses and vulnerabilities that need to be repaired and mitigated [33].

The ‘day after’ the injury is life-changing, as individuals face both the injury itself and its irreversibility [16]. Daily-life activities are profoundly affected, often requiring assistance that may be difficult to accept. Individuals with SCI experience a mismatch between their physical abilities before and after the injury, making it hard to adapt former sport practices. Although many must give up the sport they previously played, the desire to restart was still present among the participants.

Participants reported a renewed appreciation for sport after injury, trying new disciplines and practising them for a period of time to adapt their physical abilities and enjoy the experience. A SCI can foster personal growth by promoting mind-set changes and activating previously unrecognized personal resources [32].

Concerning access to sports, environmental and accessibility barriers still represent a struggle, preventing sport participation for people with disabilities. Participants reported lack of money and time as major limitations, in addition to the paucity of proper facilities and the lack of local initiatives promoting sports for individuals with disability. Individuals with SCI are interested in undertaking sports after injury, but perceived limitations, especially for outdoor activities, might outweigh their intention to do so. Providing information on the health benefits of sport from the time of hospitalization could support engagement. In addition, the presence of local organizations would be beneficial to spread information about sport disciplines for individuals with SCI and promote their participation. These themes agree with previous literature about sport accessibility in adults with disability [16,34].

These existing barriers to sport participation directly inform participants’ assessments of FES-cycling’s practical viability: concerns about cost, the need for assistance in setup, transportation difficulties and lack of accessible outdoor infrastructure (Theme V) reflect not merely technical limitations of the devices, but the broader systemic barriers that already constrain sport participation for individuals with SCI.

Despite these concerns, participants’ experience with FES-cycling devices tested in the study was overall positive. Apart from some frustration due to the mismatch between expectations and results, participants reported a clear sense of satisfaction and well-being. This positive experience was nurtured not only by the opportunity to test innovative FES-cycling devices, but also by the meaningful social interaction with other testers and the researchers [8,35].

The last theme reported in this study was about future perspectives: outdoor use of FES-cycling was hypothesized as a way to improve mobility and have a different interaction with the outdoor environment. This could be beneficial according to environmental psychology, studying the interplay between the individual and the places they experience [36]. Socializing was another opportunity that the participants reported as a potential for FES-cycling devices, allowing individuals to meet others. This entails both interacting with peers with same or similar conditions or participating in competitions. This opportunity to socialize is alternatively described as the possibility for individuals with SCI to find their community [20]. Using the bike for competitions was also mentioned by some participants, while others envisioned a hybrid use, combining leisure activity with benefits for both physical fitness and mental well-being. Although participants experienced the devices over a limited number of sessions, many were able to envisage their use beyond the rehabilitation setting, describing FES-cycling as a potential means of engaging in regular physical activity and, for some, sport participation. This is consistent with the recent success of competitions such as the FES sports days and Cybathlon [37].

Overall, the findings suggest that FES-cycling can offer meaningful experiences related to social interaction, mental well-being and community engagement. Rather than viewing FES-cycling solely as a rehabilitation technology, participants frequently associated its future use with opportunities to access the broader physical, psychological and social benefits traditionally linked to physical activity and sport. These insights contribute to expanding the concept of activity-based therapy (ABT), going beyond functional recovery to include community-based interventions addressing physical, psychological and social outcomes [38,39]. In this perspective, FES-cycling may be viewed not only as a rehabilitation exercise but also as a form of ABT with recreational value and potential long-term benefits [40,41], extending its role from a hospital-based intervention towards a technology that may facilitate engagement in meaningful physical activity within everyday life.

Alongside future perspectives of outdoor FES-cycling use, this study acknowledges also the barriers, both on a personal and on a contextual level. On a personal level, participants described challenges such as fatigue, pain and the difficulty of applying electrodes independently, with a consequent reduced sense of independence. Contextual elements, such as traffic visibility, geographic location and the practicalities of manoeuvring and transporting the bike, also affected the future use of the devices.

From the immediate surrounding environment to the broad societal structures, human ecological models conceptualize the interplay between the individuals with disabilities and the barriers to physical activity participation across four domains: intrapersonal (personal perspective and attitudes), interpersonal (social relationships with friends and family), organizational (staff, program and policy) and community based (safety) [42,43]. The barriers to physical activity at the broader levels of the model might affect the ecological domains to the bottom, and vice versa: for instance, without inclusive cities equipped with appropriate infrastructure, the practical use of such technologies remains limited and potentially inequitable. The introduction of accessible cycling paths might increase the sense of security, improving the visibility of the cycling device. Likewise, the introduction of organizations supporting FES-cycling programs might spread this initiative and support its realization, creating a network of socialization and support. Existing institutions, such as hospitals or rehabilitation centres, could also take on this role and help integrate FES-cycling into established physical activity and sport pathways.

In summary, this qualitative analysis contributed to the investigation of factors affecting the long-term use of FES-cycling devices by individuals with SCI: the onset of personal resources and the willingness to participate in physical activity and sport programs, suggest the users’ readiness to engage in FES-cycling programs. Positive experiences and attitudes about the future use of the bikes should consider potential barriers on different levels of the ecological framework, otherwise, the devices might not be considered for use at all.

This study has limitations. First, the sample was composed of only male participants, preventing the generalizability of the results to women with SCI. Nevertheless, subjects with SCI are more often males due to the higher probability of performing high-risk jobs as well as the higher use of motorcycles [44]. Further research including female participants is warranted to explore whether gender-related factors may influence perceptions, experiences and usability evaluations of FES-cycling. A second limitation of this study is the absence of a longitudinal follow-up. Although participants were able to compare the two FES-cycling systems after completing the training sessions, the study did not investigate whether they subsequently had opportunities to use these or similar devices, nor whether their perceptions, preferences and willingness to use FES-cycling evolved over time. Longer-term follow-up would provide valuable insights into users’ adaptation to the technology, the sustainability of device use, and the stability or evolution of participants’ views beyond their initial experiences. Another limitation of this study concerns the composition of the study sample. Given the exploratory nature of this qualitative investigation, a purposive heterogeneous sample was recruited to encompass participants with different demographic and clinical characteristics, including age, chronicity of SCI, lesion severity and previous sporting experience. Also, all participants were naïve to FES-cycling and experienced the technology over a limited number of sessions; therefore, the findings should be interpreted as reflecting initial experiences rather than long-term adaptation or sustained engagement with FES-cycling. Accordingly, this study was not primarily designed to examine the potential influence of these characteristics on participants’ perceptions and experiences of FES-cycling, nor to compare responses across subgroups. Future research could address these limitations by involving broader and more heterogeneous participant samples, enabling a more in-depth investigation of whether these factors contribute to differences in users’ experiences and perceptions of FES-cycling, while enhancing the generalizability of the findings. To address these limitations, future studies could benefit from adopting a mixed-methods approach, integrating quantitative paradigms with an explanatory aim to examine potential associations between individual characteristics and FES-cycling experiences, alongside qualitative methods such as focus groups. The latter could provide valuable insights into the interpersonal and group-level dynamics, allowing for the collection of shared perspectives and attitudes. This approach would contribute to a more comprehensive understanding of how FES-cycling devices are perceived and utilized within training programs and sports contexts.

Conclusions

This study identified factors that may influence participants’ perceptions and future engagement with FES-cycling by examining user experiences within the broader context of sport participation history and values. The results of this investigation suggest that FES-cycling may extend beyond its conventional rehabilitative role, offering opportunities for physical, psychological, and social engagement and potentially supporting sustained participation in physical activity and sport. Personal, practical and environmental barriers counterbalanced participants’ positive experiences and future-oriented perspectives. These findings highlight the need to consider FES-cycling within a broader ABT framework, where sustained use depends not only on the technology itself but also on accessible environments, supportive programs and opportunities for meaningful community participation.

By understanding what individuals with SCI value in sport, the barriers they face, and how their motivations evolve post-injury, this study provides insights into the factors that may shape the perception and acceptance of FES cycling beyond rehabilitation settings. Excitement for these devices must be aligned with realistic expectations and practical support. A space for dialogue addressing device limitations and user concerns is essential to support the broader adoption of FES-cycling in outdoor settings and its potential role in meaningful physical activity and sport participation that aligns with users’ goals and lived realities.

Funding Statement

This work was supported by INAIL (Istituto Nazionale Assicurazione contro gli Infortuni sul Lavoro) within the FESleg project (PR19-RR-P5). This work was also partially supported by the Italian Ministry of Health (Ricerca Corrente 2023/2026 to E. Biffi).

Ethical approval

The study was conducted in accordance with the Declaration of Helsinki and was approved by an Institutional Review Board/Ethics committee.

Disclosure statement

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

Data availability statement

The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials. Additional data may be available from the corresponding author on reasonable request due to privacy and ethical restrictions.