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Management Brief No. 154

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Management eBriefs
Issue 154April 2019

The report is a product of the VA/HSR Evidence Synthesis Program.

Adaptive Sports for Disabled Veterans: Systematic Review

For persons with physical disabilities, organized sports can be traced back to the early 1900s, but opportunities expanded greatly in the post-World War II era when adaptive sports began to be used to rehabilitate Veterans.

The term "adaptive sports" is used to describe a sport that has either been adapted specifically for persons with a disability or created specifically for persons with a disability.

Many of the early adaptive sports programs were in downhill skiing. Since then, the range of available sports and opportunities for participation at all levels — from recreational to competitive — has broadened greatly. Within VA, the vision of VA's Office of National Veteran Sports Programs & Special Events (NVSP&SE) is "to be leaders in the provision of adaptive sports and therapeutic arts programs that complement VA's rehabilitation system of care for Veterans and members of the Armed Forces with disabilities." The national rehabilitation events are intended to "provide opportunities for Veterans to improve their independence, well-being, and quality of life through adaptive sports and therapeutic arts programs."

This systematic review examined the available evidence on the benefits and harms of participation in adaptive sports programs, as well as the barriers to and facilitators of participation. Investigators with VA's Evidence Synthesis Program (ESP) Center in Minneapolis, MN reviewed the literature identified from searches of the MEDLINE®, EMBASE, SPORTDiscus, and Rehabilitation and Sports Medicine Source databases from 1995 to July 2018. After a full-text review of 450 articles, investigators included 118 articles representing 114 studies; of these, 24 articles provided data on elite athletes (i.e., Paralympians or World Championship participants) and were not included, as findings would be of limited applicability to the Veteran population.

The medical conditions in this review included: amyotrophic lateral sclerosis (ALS), limb amputation, hearing loss or deafness, multiple sclerosis (MS), post-traumatic stress disorder (PTSD), spinal cord disorder, spinal cord injury, stroke/cerebrovascular accident (CVA), traumatic brain injury, or visual impairment or blindness. The adaptive sports in this review included: alpine skiing, archery, billiards, boccia, climbing, curling, cycling, Equine-Assisted Activities and Therapies (EAAT), golf, hand-cycling, kayaking/canoeing, Nordic skiing, para-triathlon, sailing, shooting, sitting volleyball, sled hockey, surfing, swimming, table tennis, tennis, weightlifting-power lifting, and wheelchair basketball, fencing, lacrosse, and rugby.

Summary of Findings

  • Evidence for the effectiveness of adaptive sports programs is largely from studies of Equine-Assisted Activities and Therapies in selected interested and eligible individuals with PTSD, MS, or CVA.
  • Evidence is limited to inform developing, implementing, making available, and evaluating the effects of adaptive sports programs or informal adaptive sports participation.
  • There is insufficient evidence for other adaptive sports or populations, and it is unknown whether findings from a particular sport — in a particular population — are generalizable.
  • There was little evidence of harms associated with adaptive sports program participation although, again, few adaptive sports or populations of interest were represented in the literature.
  • Barriers to participation were similar across conditions and sports, and were mainly related to physical environmental factors (e.g., cost, accessibility, and transportation concerns). Personal barriers included fear of injury or pain, lack of time, and low self-esteem.
  • Facilitators of participation included social factors (e.g., social contacts, participation in society, interaction with others with similar disabilities) and personal beliefs (e.g., improved health/fitness, increased self-esteem, improved skills, and new experiences).

Limitations of the available literature include generally low quality of evidence (i.e., non-randomized designs, small sample sizes, selected populations) and few studies for many of the adaptive sports and conditions of interest. Disabling conditions were often self-reported and little information was provided about the severity of the condition, etiology, comorbidities, or participant demographics. Marked variation in populations, interventions, and outcomes assessment limited assessment of effect consistency or applicability. Few studies provided follow-up data to ascertain whether participation continued and/or whether benefits were maintained.

Implications for Current Practice and Policy
Findings from the evidence review suggest that NVSP&SE continues to expand and/or develop opportunities for participation in adaptive sports for broader populations of interested Veterans and service members. The Adaptive Sports Grant Program—facilitated and managed by NVSP&SE—provides a path for expanded program offerings. The Grant Program encourages federal agencies to partner with non-federal entities to jointly create national, regional, and community-based programs that provide adaptive sports activities for disabled Veterans and members of the Armed Forces. Program specifics may vary depending on the population, providers, and setting, but program developers might consider initiating programs early in the rehabilitation process, offering follow-up programs, and continually evaluating the net value of the programs. NVSP&SE might also explore ways to decrease barriers to and increase facilitators of participation including enhancing access and reducing perceived or real fears/harms. NVSP&SE programs could build on perceived benefits of participation including social interaction, participation in society, and sense of improved health/fitness.

Future Research
Findings strongly support the need for rigorous design and outcome evaluation across a spectrum of individuals, health conditions, interventions, and settings. Because there is general agreement that sports participation should be encouraged, future questions also should examine how to increase participation among populations with physical challenges that differ from those not requiring sport activity adaptation. The Adaptive Sports Grant Program also may provide opportunities for future research.

The cyberseminar on Adaptive Sports for Veterans: A Systematic Review of the Evidence will be held on May 22, 2019 from 1:00pm to 2:00pm ET. Register for this session.

Greer N, Balser D, McKenzie L, Nicholson H, MacDonald R, Rosebush C, Senk A, Tonkin B, Wilt, TJ. Adaptive Sports for Disabled Veterans. VA ESP Project #09-009; 2019.

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ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.


This report is a product of VA/HSR&D's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers – and to disseminate these reports throughout VA.

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