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The effects of sport on social participation, community integration, and perceived quality of life
for individuals with mobility impairments
A Literature Review

Angela Crawford

Completed for:
David Gray, Ph.D.
July 6, 2006

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Addressing the Problem
Despite the proven individual and social benefits of sport and active recreation (ICF
d9201) for individuals with mobility impairments, this population is less likely to engage in
physical activity than those without disabilities (Healthy People, 2010; Rimmer, Riley, Wang,
Rauworth, Jurkowski, 2004). Scelza, Kalpakijan, Zemper, and Tate found that the most limiting
factors in relation to sport and active recreation participation were those other than disability
related characteristics (2005). Therefore, individuals with mobility impairments may be more
likely to participate in sport and active recreation if they experienced less limiting extraneous
factors.
Proven benefits of sport and recreation include an increase in physical (ICF d410, d415,
d440, d435, d445, d455) and psychological components, overall health, subjective well being,
community reintegration (ICF d910), and social participation when compared with inactive
individuals with mobility impairments. Physically, sport has been proven to increase strength,
stamina, fitness, mobility, coordination, endurance, posture, weight control, immune function,
cardiopulmonary function, and circulation (Guttmann, 1976; Jackson, 1987; Jackson & Davis,
1983; Shephard, 1991). Psychological benefits include a better acceptance of disability, more
independent attitude, less suicidal attempts due to decreased depression and anxiety, enhanced
mood, and a greater sense of life control (Guttmann, 1976; Jackson, 1987; Kerstin, Gabriele,
Richard, 2006; Muraki, Tsunawake, Hiramatsu, Yamasaki, 2000; Valliant, Bezzubyk, Daley,
Asu, 1985). Overall health benefits due to sport activity have been described as decrease in
secondary conditions and the need to seek medical care, increased functional independence,
energy, and physical capacity (Curtis, McClanahan, Hall, Dillon, Brown, 1986; Dallmeijer,
Hopman, van As, van der Woude, 1996; Hanson, Nabavi, & Yeun, 2000; Muraki et al., 2000;

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Rimmer et al., 1999). Subjectively, sport participants have been shown to have a greater self
image and self satisfaction, increased confidence, self esteem, perceived health, body image, and
self resilience (Jackson, 1987; Manns & Chad, 1999; Shephard, 1991; Tasiemski et al, 2005;
Wetterhahn, Hanson, Levy, 2002). Furthermore, low levels of community integration have been
shown to correlate with low quality of life; however, because sport increases quality of life,
community integration may improve as well (Hanson et al., 2000). In 1975, Guttman (referring
to individuals with mobility impairments) stated, Indeed, it is the noblest aim to facilitate and
accelerate his reintegration into the community, and his recognition as an equal and respected
citizen. Athletes may participate in community organized athletic, social, advocacy, or
educational events which increases community integration (Stotts, 1985). Finally, sport and
recreation increases social participation (ICF d750, d350). Individuals must participate socially
in society in regards to obtaining equipment, talking to current athletes and coaches, and being
involved on a team (Wu & Williams, 2001). Social roles can be fulfilled more easily considering
physical and social benefits, increased social relationships, and increased support associated with
sport and active recreation (Hanson et al., 2001; Tasiemski et al, 2005).
In addition to personal benefits, participation of individuals with mobility impairments in
sport and active recreation has societal and economic benefits. In 2001, Wu & Williams showed
that in comparison with non athletes, individuals who participated in sport were more likely to
support a family, maintain a job and go to school (ICF d820, d825, d830, d845, d850).
Psychosocial factors such as increased mood, decreased anxiety and depression, better self
esteem and life satisfaction have been shown to be more important in determining employment
than physical functioning. Sport programs should be seen as an attractive investment to society
because of the potential they have in cutting medical costs and enhancing productivity (Noreau

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& Shephard, 1992; Shephard, 1991; Tasiemski, 2005). Athletes with mobility impairments have
less frequent and less expensive hospitalizations due to skin breakdowns and other secondary
conditions (Stotts, 1986). Furthermore, athletes who participate in sport can help counter social
stigmas of helplessness and dependency, and act as advocates in the community.
Healthy People 2010 states that over half of people with disabilities are not physically
active compared with about a third of able bodied individuals (2000). Various reasons for the
lack of physical activity include environmental barriers, lack of opportunity, lack of information,
and other personal factors. A common source of environmental barriers include physical and
architectural barriers such as absence or poor condition of curb cuts, inaccessible parking and
entrances, poor travel surfaces, lack of elevators and handrails, and counters and desks that are
too high (ICF e150, e 155, e160). In addition, state, city and local policy and procedures can act
as a barrier to participation (ICF e550 ,e555) as well as the social and familial context of an
individual (ICF e310-e499). Facility members and owners as well as family members may
believe that sport participation is not important, appropriate, or feasible for the individual
(Rimmer et al., 2004). An equally important social barrier is the lack of recognition for athletes
with disabilities (ICF e560). They are not always viewed as serious competitors, and games even
at the international level are not televised (Jackson & Fredrickson, 1979; Monahan, 1986).
Although opportunities and information for individuals with disabilities interested in
playing sports are growing, they still do not equal those of able bodied athletes. Factors such as
lack of transportation (ICF e120, e540), inadequate resources to buy equipment (ICF e550, e555)
and inaccessible equipment for rental or purchase can also be classified as a lack of opportunity
for participation (ICF e140). Potential athletes are also faced with the problem of obtaining
information about accessible facilities and equipment, local sport teams, clubs, or program

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opportunities, and funding for equipment purchase and skills training (ICF e580). Individuals
with mobility impairments do not receive substantial education, information, or resources in
rehabilitation and are not exposed to opportunities for athletes with disabilities through the media
(Kerstin et al., 2006; Rimmer et al., 2004; Wu & Williams, 2001). Although not initially
obvious, these obstacles can greatly hinder sport participation for those who might be interested.
Various personal factors can be barriers to sport participation as well. Illness, disability
characteristics, secondary conditions, wheelchair complications, or poor body image may deter
participation because of the fear of failure or public exposure (Rimmer et al., 2004; Taylor &
McGruder, 1996; Wetterhahn et al., 2002). Lack of motivation and energy, negative attitudes,
and low self esteem or confidence can also be attributed to non participation (Furst, Ferr,
Meggison, 1993; Scelza et al, 2005). Finally, individuals have to be psychologically ready to
participate in sports after an injury, and in the appropriate stage of change in order for readiness
to emerge. Using the transtheoretical model (TTM) an individual must be past the
precontemplation stage before they even consider a behavior change. Supplementing with the
health belief model, the individual must also recognize the health benefits of participating in
sport before he or she displays readiness. Although there are many barriers facing sport and
active recreation participation, many athletes find a way to participate in sports.
Individuals with mobility impairments who participate in sports practice adaptation
strategies. Some of these strategies include finding a role model, goal setting, acquiring
knowledge, accepting assistance, and finding environmental solutions. Individual motivation
may increase by becoming a role model, experiencing better health and enjoyment from sport,
becoming part of a social network, and gaining and maintaining independence (Kerstin,
Gabriele, Richard, 2006). In addition, individuals who participate in sport and active recreation

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are more likely to have been an athlete pre injury and are most commonly influenced to become
involved in sports through encouragement from other friends or acquaintances with disabilities
who play sports, followed by friends without disabilities, therapists, and coaches (Wu &
Williams, 2001). The most common reasons for participating in sports are fun, rehabilitation,
decreasing pain, getting out of the house, keeping active, socialization, competition, and fitness
(Kerstin et al,, 2006; Tasiemski, Bergstrom, Savie, Gardner, 2000; Tasiemski, Kennedy,
Gardner, Taylor, 2005; Wu & Willams, 2001). Wu & Williams showed that athletes often
express feelings of wishing to have become involved in sports sooner and manifesting emotions
of gratitude and joy at having started participating in sport and active recreation (2001).
Theoretical Models
The independent living (IL) movement had origins in the 1920s and 1930s with
spokesmen and advocates such as President Roosevelt and Helen Keller. As the IL movement
progressed, independent living centers opened and students in wheelchairs started living on
school campuses (Martinez & Duncan, 2003). The movement exploded in the 1970s
piggybacking on the civil rights movement. With the passage of the 1973 Rehabilitation Act
affirmative action policies for employment and architectural guidelines were set in place. In
addition, section 504 banned discrimination on the basis of disability from any programs
receiving federal financial assistance (DeJong, 1979). From that point the IL movement helped
change ideas behind practice and policy in the area of disability rehabilitation by showcasing the
values of a more social model of disability opposed to the medical model from which practice
and policy had previously been guided.
The medical model is on based etiology progressing to pathology which progresses into
manifestations of symptoms (Gray & Hendershot, 2000). The main underlying assumption of the

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medical model is that disability results from the inadequate performance and impairment of the
individual. Within the medical model, the person with a disability is expected to assume the sick
role which assumes that the physician is the primary decision maker and ultimate authority, the
main purpose of treatment is restorative care, and the individual is not expected to have any
responsibility within society. However, individuals with disabilities progress from the sick role
to the impaired role once they cannot be cured through acute treatment. In the impaired role,
individuals spend their days as children and are not treated as productive members of society
(DeJong, 1979).
The IL movement rejects the medical model, sick, and impaired roles with the
assumption that individuals with disabilities are being denied their right to participate. The IL
paradigm which is a more social approach to disability recognizes that the disability does not
reside within the person but in the lived environment. This shift in attitude has led to the opinion
that those with disabilities are the experts on their disability and current treatment. Currently, the
main focus in rehabilitation changing is more client centered and has a compensatory focus in
addition to restoration components. Finally, this new model is starting to cast individuals with
disabilities in a different light which is dissolving the sick role, erasing social stigma, and
emphasizing their right to participate in society (DeJong, 1979).
Dr. Thomas Glass criticized the medical model on the grounds that the model reflects an
emphasis on functional ability as a hypothetical construct (can do), rather than actual daily
performance in an enacted construct (do do). The medical model does not measure functional
ability in the world but instead is based on assessing the can do measured by self report on
what an individual perceives he or she is able to do without real world restraints, or the could
do measured by observation of performance in a controlled setting such as a clinic. The IL

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movement has helped change the mind set that individuals with disabilities cannot live and
function independently in the real world, yet most assessments of functional ability are still
assessed as a hypothetical or experimental construct. Glass proposed that more measures in the
enacted construct need to be developed to fully capture functional ability in the real world.
However, he concluded all three tenses need to be measured to the get best all around picture of
functional ability, but currently measures of the enacted tense are not being assessed as much as
the hypothetical and experimental tense (Glass, 1998).
The ICIDH and ICIDH-2 were developed to classify the consequences of a disease or
disability instead of the mere diagnosed condition (Gray & Hendershot, 2000). From these the
ICF was created which added environment as a factor which will affect disease or disability
outcomes. The goal of the ICF is to provide a standard language and framework for the
description of health and health related states and to provide a systematic coding scheme. The
environmental aspect was added to the ICF because of the shift in thinking that the disability
results from a problem within the person to thinking that disability results from the lived
environment (WHO, 2001). The World Health Organization defines impairments as problems in
the body function or structure as a significant deviation or loss, disability as the consequence of
the impairment in terms of functional performance, participation as involvement in a life
situation, and handicap as the disadvantage and inability to fulfill a social role as a result of an
impairment or disability (Gray & Hendershot, 2000; WHO, 2001). Figure 1 shows the ICF
model and the interaction between body function and structure, activity and participation, and
environmental and personal factors. Figure 2 is an example of how playing tennis in a manual
wheelchair fits within the context of the ICF.

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Figure 1: International Classification of Functioning and Disability, Word Health Oraganization, 2001

Body function and structure

Mobility impairment
Secondary conditions
(skin breakdown, decreased
cardiopulmonary functioning, depression,
anxiety)
Strength and ROM, Posture,
Spasticity, Trunk stability, Spasms,
Incontinence
Weight, Coordination, Endurance

Environmental Factors
Transportation
Family and social attitudes
Architectural (building, parking
lots, sidewalks, courts)
Equipment
Lack of opportunity and
information

Activities and Participation

Actively learn and practice the game
Learn scoring system
Serve/Return the ball for a volley
Social interaction with coach, athletes,
spectators
Competing in a game
Maneuver tennis chair
Grasp and swing racket

Personal Factors
Depression, Motivation
Attitude, Stage of Change
Confidence, Self-efficacy
Resources, Age

Figure 2: Body functions and structures, activities and participation while playing tennis in a manual
wheelchair affect and are affected by environmental and personal factors

Motivation or readiness to participate in sports is most commonly explained by stages of

change through the TTM. In the precontemplation stage the individual has no intention of

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becoming active, in the contemplation stage the individual is thinking about starting to become
physically active in the next six months, the preparation stage is when the individual makes small
changes in behavior but does not consistently participate, action is becoming physically active in
the last 6 months, maintenance is being physically active for more than six months, and finally
termination is when an individual stops maintaining physical activity for any reason. Although
this model has traditionally been presented linearly, progression is more likely to follow a
cyclical pattern through the stages (Marshall & Biddle, 2001). Figure 2 show the cyclical pattern
of the TTM through all of the stages of change.

Figure 3: Transtheoretical Model of stages of change for physical activity

Recently, van der Ploeg, van der Beek, van der Woude, and van Mechelen
have developed a conceptual model called Physical Activity for People with Disabilities
(PAD). It is based in part off the ICF and consists of three levels of activity functioning which
are body functions and structures, activities, and participation. Physical activity is a part of all
three level of functioning and benefits span throughout these three levels. In addition,
environmental barriers and personal factors such as attitude and self efficacy can have a great
influence on the opportunity and ability of a person to participate in physical activity (2004).

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The opportunity for an individual with a disability to participate in sport and recreation
has increased as a result of the IL movement and shift to the social model. Sports increase the
can do based on measuring hypothetical constructs, but also increases the do do based on
self report of occupational performance and productivity in society. However, athletes must be
careful not to participate so much in sport and recreation that their participation in other areas of
occupation decreases as a result of time constraint or other factors. Therefore, future theoretical
models will most likely consider the importance of measuring the enacted tense (do do) when
assessing functional ability, and considering environmental factors when assessing how
disability affects participation.
Background
Sport and active recreation are different terms used in the literature, meaning very similar
things. They are defined differently across countries but have been said to include recreational,
playful, joyful and pleasurable aspects for the individual (Guttmann, 1975; Shephard, 1991).
Sport and active recreation have need to fit with the leisure interests, needs, and tastes of an
individual (Jackson, 1987; Stotts, 1986). For the purpose of this literature review, I am going to
narrow down the meaning of these concepts. Sport and active recreation activities need to be a
personal an enjoyable choice for an individual with any type of mobility impairments. They can
be indoor, outdoor, competitive, non competitive, individual, or team activities that have an
active physical component. Finally, these activities should not be exercise or strength training
that is a required or prescribe part of rehabilitation. Unfortunately, most of the sport activities
that exist are centered around manual wheelchair users with paraplegia with very little evidence
about opportunities for individuals who use power wheelchairs, scooters, canes, crutches, or
walkers (Shephard, 1991). Sport for people with mobility impairments may include but are not

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limited to the following: swimming, archery, basketball, table tennis, weight training, snow
skiing, track and field, tennis, racing, rugby, kayaking, canoeing, bowling, fishing, hang gliding,
parachuting, sailing, rock climbing, mountain biking fencing, and shooting (Beringer, 2004;
Hamel, 1992; Jackon, 1987; Jackson and Fredrickson, 1979; Shephard, 1991; Tasimeski et al.,
2005).
In February 1944, Sir Ludwig Guttmann founded the Stoke Mandeville Hospital in
England for injured soldiers. Guttmann valued the physical, psychological, and social
reintegration benefits of sport in the able bodied person, thus implementing sport and recreation
as an essential part of therapy for those with mobility impairments. On July 28, 1948 the first day
of the Olympics in London, the Stoke Mandeville games started as a national sports event with
16 athletes with paraplegia. The games grew to the international level and were held every year
for experts and beginners alike. Guttmann was knighted in 1966 for his significant contribution
to treatment of people with paraplegia. Sport for those with disability continued to grow as the
first Paralympics were held in 1960 after the regular Olympics in Rome. In 1976 the Toronto
Olympiad was the first sporting event which included those other than manual wheelchair users.
In 1980 the formation of the International Coordinating Council for athletes with disabilities was
formed, and in 1984, inclusion demonstrations by athletes with disabilities took place at both the
winter and summer Olympic Games. Currently equipment innovations and attitudinal changes
have created more opportunities to participate and compete in sport (Guttmann, 1975; Guttmann
1976; Hamel, 1992; Jackson, 1987).
It is estimated that 13-20% of the Western population has one or more disabilities, and
56% of this population does not participate in physical activity compared with 36% of the able
bodied population (Healthy People, 2010; van der Ploeg et al., 2004). However, sport and

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active recreation have been shown to decreases disability by increasing overall physical and
psychological health, creating a social support network increasing independence, promoting
community re-integration, and increasing quality of life and perceived life satisfaction.
Specifically sport increases independence, functional mobility, social participation, and
community reintegration which has been shown to increase life satisfaction in life as a whole,
specifically ability to manage self care, vocational situation, financial situation, sexual life,
family life, contact with friends, and leisure situation (Beringer, 2004; Manns & Chad, 1999;
Tasiemski et al., 2000; Tasiemski et al., 2005; Wu & Williams 2001).
Hypothesis
The literature has suggested many benefits to sport and active recreation for individuals
with mobility impairments, but more research needs to be conducted. Hypotheses for future
research might include:
1. Participation in active recreation serves a role model and motivator to other people with
disabilities and provides opportunity to advocate to the general population.
2. Information and exposure to sports in a rehabilitation setting will increase likelihood of
participating post rehabilitation, and speed the course to readiness through the Transtheortetical
model and Health Belief model frameworks.
Implications for Occupational Therapy
Sport and active recreation has a tremendous implication for occupational therapy. First
and foremost, OTs have a role in the rehabilitation setting to provide information and exposure to
sport and active recreation, guide the process of obtaining equipment, promote physical activity
for clients, and give contact information of coaches and athletes to anyone interested in
participating in sports. OTs need to assess readiness of clients both physically and

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psychologically, and educate families and clients of the benefits that sport has been proven to
have for individuals. Because more opportunity for sport involvement is needed, OTs can design
sport and active recreation programs or advocate for the need for more opportunities in the
community. Finally, OTs can conduct research about how sport and active recreation enables
occupation and increases social participation (DeJong, 1979; Hanson et al., 2000; Pasek &
Schkade, 1995; Taylor & McGruder, 1996; van der Ploeg, 2004; Wetterhahn et al., 2002; Wu &
Williams 2001). OTs can be involved in the creation of physical activity motivational programs
for potential athletes who are unmotivated for various reasons (Kosma, Cardinal, McCubbin,
2005). Finally, OTs can help clients maintain balance between occupational domains and
possibly become role models for potential athletes with mobility impairments (Kerstin et al.,
2006; Taylor & McGruder, 1996).
A basic theoretical assumption in occupational therapy is that engagement in activities is
related to life satisfaction. Thus, one function of the occupational therapist is to enable patients
participation in activities for which they report high levels of interest yet have low values of
satisfaction(Yerxa & Baum as stated in Seigel & McGruder, 1995). OTs need to fill the gap for
the clients who want to participate in sports but do not know how to get involved, and educate
those who might not realize the opportunities for sport participation for individuals with
disabilities. As Dr. Kenneth J. Richter states, We havent scratched the surface of the potential
pool of athletes (Hamel, 1992).

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