EXERCISE IS MEDICINE

Prescribing Exercise to Individuals with

Disabilities: What Are the Concerns?
Hector Luis Osoria, MD1 and Cheri A. Blauwet, MD1,2,3

exercise. These barriers are often both

Abstract
structural and attitudinal. For exam-
It is well known that individuals with disabilities, constituting 15% to 20% of
ple, fitness facilities and mainstream
the adult population, experience a disproportionate risk of cardiometabolic
health clubs are often inaccessible for
disease and are more likely to live sedentary lifestyles when compared
individuals with physical, sensory, and
with their able-bodied peers. Although many complex factors likely lead to
intellectual impairments, lacking the
these disparities, targeted exercise programs can be influential in improv-
programs and equipment that would
ing the health outcomes of this population. Additionally, it is important to
enable universal participation (37,43).
keep several factors in mind when tailoring the exercise prescription for
Given that individuals with disabilities
individuals with varied types of disability, given unique factors related to
are more likely to experience socioeco-
medical history, mobility, and community barriers. By safely engaging in-
nomic challenges, issues such as pro-
dividuals with disabilities in exercise programs, clinicians can promote
gram costs and lack of transportation
inclusion while making a significant contribution to health outcomes, en-
are frequently prohibitive (38). Children
suring that the principles of ‘‘Exercise is Medicine’’ are accessible to in-
with disabilities face additional barriers
dividuals of all abilities.
in accessing opportunities for recreation
and active play when compared with
their able-bodied peers (51). Despite
Introduction this, a study indicated that people with disabilities are moti-
It is well known that being physically active offers bene- vated and eager to exercise once these barriers can be
fits to physical and mental health. Additionally, access to overcome (38). Additionally, health professionals have a re-
sports opportunities and community-based exercise are sponsibility to ensure that concepts of ‘‘Exercise is Medicine’’
considered mainstays of health promotion. In Healthy are applicable to individuals of all abilities (13).
People 2020, the United States Department of Health and Here, we provide a review of the most recent literature
Human Services outlined 10-yr, evidence-based objectives regarding the impact of exercise on individuals with a dis-
with a goal to improve the health of all Americans, inclusive ability, with particular focus on cardiometabolic health,
of individuals with disabilities (22). Despite this, individuals mental health, capacity for neurorecovery, and community
with disabilities continue to experience a disproportionate participation. We additionally provide an overview of the
rate of chronic disease, such as obesity, diabetes, and car- potential health concerns that must be kept in mind when
diovascular disease (CVD), likely due to the compounded prescribing exercise to individuals with disabilities to en-
effects of immobility and sedentary lifestyles (18). courage safe and effective engagement.
Concomitantly, it is known that people with disabilities
often face multiple, complex barriers to engagement in
Exercise Considerations Based on Disability Type
1
Department of Physical Medicine and Rehabilitation, Harvard Medical School,
In the following section, we provide an updated overview
Spaulding Rehabilitation Hospital, Charlestown, MA, 2 Brigham and Women’s (literature published in 2014 to 2017) of considerations re-
Hospital, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, garding prescribing exercise to individuals with several
MA, and 3Kelley Adaptive Sports Research Institute, Harvard Medical unique types of disability. The literature search was con-
School, Spaulding Rehabilitation Hospital, Charlestown, MA
ducted on PubMed using three-word phrases which con-
Address for correspondence: Cheri A. Blauwet, MD, Department of tained one word from each of the following categories in all
Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding possible combinations: 1) exercise, sport, recreation, physical
Rehabilitation Hospital, 300 1st Avenue, Charlestown, MA 02129; E-mail: activity; 2) restriction, limitation, prescription, barrier; 3)
[email protected]. stroke, cerebrovascular accident, brain injury, spinal cord
1537-890X/1604/268Y273
injury (SCI), spinal cord disease, spina bifida, multiple
Current Sports Medicine Reports sclerosis (MS), amputee, amputation, limb loss, blind,
Copyright * 2017 by the American College of Sports Medicine deaf, neuromuscular disease, cerebral palsy (CP), muscular

268 Volume 16 & Number 4 & July/August 2017 Prescribing Exercise to Individuals with Disabilities

Copyright © 2017 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
dystrophy, trisomy 21, and/or Down syndrome. The articles was demonstrated that individuals with SCI can achieve
were reviewed and selected by the first author (H.L.O.) for weight loss at a rate similar to individuals with no disability
relevance to this current topic, yielding a total of 47 articles who receive comparable intervention.
used for this writing. Regarding category 3, although these In addition to the potential metabolic and cardiovascular
terms are not fully representative of the full spectrum of benefits of exercise, studies in animal models have revealed
disability, which is quite heterogeneous, they form a repre- the potential for exercise to stimulate neurologic recovery
sentative sample of the types of impairment most com- after SCI. Early studies reveal the potential for exercise to
monly observed within the community and where prior improve neuropathic pain after SCI, to stimulate axonal
literature has explored the unique benefits and/or risks of regeneration, and to alter the cellular milieu of the spinal
engagement in exercise. cord postinjury. Further investigation is required to deter-
mine if the impact of exercise is similar in humans (41).
Spinal cord injury and disease Despite the myriad benefits of exercise in individuals with
The impact of exercise and physical activity has been SCI as outlined above, there is consistent evidence that cli-
studied fairly extensively in individuals with SCI and dis- nicians often fail to recommend physical activity in-
ease. This is an important and active area of research given terventions to this population. In a study of physical therapy
that individuals with SCI are known to be at higher risk for practices, Williams et al. (48) revealed that exercise as a
CVD and metabolic syndrome. This is particularly true in lifestyle change was rarely recommended, despite the clini-
older individuals, those with greater years postinjury, and cian’s knowledge regarding its various benefits. Individuals
those with lower levels of education (16). More recently, with SCI also frequently experience barriers to engagement
one randomized control study sought to investigate the ef- in exercise that are complex and multifactorial. A study by
fects of upper extremity aerobic exercise, compared with Hwang et al. (24) noted that personal (e.g., low motivation,
simple strength training exercises alone, on exercise capac- pain, scheduling challenges), environmental (e.g., lack of
ity and other cardiometabolic health factors in individuals access to specialized programs), and activity-related (e.g.,
with SCI. This demonstrated that even a 12-wk program equipment limitations, lack of personal skill) barriers often
can improve exercise capacity; however, further training is coexist, limiting engagement in exercise by individuals with
likely needed to impact other outcomes such as functional SCI. Additionally, being dependent on others to assist with
status, quality of life, and parameters related to metabolic self care dramatically decreased the odds of achieving the
syndrome (1). A recent randomized control trial (RCT) World Health Organization recommended guidelines for
implemented a program that promoted physical activity for physical activity, possibly due to the increased time required
individuals with SCI beginning 2 months before and con- for activities of daily living (ADL) (36). Of note, these fac-
tinuing 6 months after discharge from inpatient rehabilita- tors were found to be present not only in individuals with
tion. This intervention resulted in clinically significant SCI but also in those with other causes of lower limb spas-
improvements in blood pressure, total cholesterol, and ticity, namely, stroke and MS, indicating that targeting
overall physical activity participation, demonstrating that physical activity promotion and facilitation may be achiev-
the early promotion of physical activity after acute SCI may able based on functional impairments and not just based on
be an effective tool for chronic disease prevention and diagnosis (23). Finally, it has been noted that secondary
health promotion (35). complications after SCI could serve as a barriers to physical
Though the benefits of physical activity within this pop- activity in addition to the physical and environmental bar-
ulation are apparent, the actual exercise prescription for riers listed above. One cross-sectional study explored the
individuals with SCI may require modifications when relationship between secondary health complications and
compared to the general population. For example, partici- physical activity in persons with traumatic SCI, noting that
pants with motor complete paraplegia SCI were found to secondary health complications, such as pain and fatigue
achieve the recommended 1000 kCal/week of energy ex- negatively influenced participation in activities. Addition-
penditure when engaged in manual wheelchair propulsion ally, individuals who lived an additional 36 to 55 yr after
for 43 min/day, 7 days/week (33). This may be helpful in SCI participated in fewer recreational activities (32).
providing a benchmark for physical activity recommenda-
tions within this population. Additionally, it is important to Acquired brain injury (traumatic brain injury and stroke)
note that in one study, individuals with SCI reported greater As is the case in SCI, the impact of physical activity on
enjoyment with programs focused on high-intensity interval both cardiometabolic health and neurorecovery likely play
training and sprint interval training rather than continuous an important role after stroke. One systematic review re-
exercise modalities (3). Unfortunately, as is the case in the cently investigated the impact of aerobic exercise on cog-
general population, it also has been noted that these bene- nitive and motor performance after stroke, noting that (a)
ficial gains can be lost after exercise is discontinued (19). low- to moderate-intensity aerobic exercise, initiated within
Regarding community-based health programs, Betts and 5 d of the stroke, improved coordination in animal models;
Froehlich-Grobe (5) completed a small pilot study through (b) balance and lower limb coordination improved with
which a mainstream exercise and weight loss program (fo- aerobic exercise regardless of exercise modality; and c) an-
cused on encouraging reduced caloric intake and increased imals that participate in poststroke exercise showed im-
energy expenditure) was made accessible for individuals proved learning and memory (21). Supporting these
with SCI. After modifications were implemented, for ex- findings in humans, a recent Cochrane review noted that
ample, having group meetings by phone and adapting the cardiorespiratory (aerobic) training improved functional
content specifically for people with impaired mobility, it ambulation, increased maximal and preferred walking

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Copyright © 2017 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
speeds, and increased walking endurance after stroke, lack of suitable programs and lack of awareness of pro-
whereas mixed cardiorespiratory and resistance training grams (29). This demonstrates that even among knowl-
was found to improve preferred walking speed and meters edgeable providers, there remains a need for greater
walked in 6 min (42). advocacy and education about the importance of engage-
In a recent RCT, both low- and high-intensity exercise ment in these programs.
groups showed improvements in speed, balance, and affected Of interest, Devine et al. (17) sought to investigate whether
lower-limb strength (28). These overall improvements in func- it was feasible for a small cohort of eight community-
tional mobility may translate to more specific tasks, such as dwelling individuals with moderate-to-severe TBI to inde-
ADL in stroke survivors. Indeed, after a 12-month community- pendently adhere to a nonsupervised exercise program and
based exercise and patient education program, one study thus improve cardiovascular endurance. This study specifi-
showed that individuals who had experienced a stroke were cally did not seek to create an exercise regimen, but instead
better able to perform ADL compared with the individuals to determine whether individuals could adhere to a self-
who underwent usual treatment (8). Additionally, the risk of determined program with minimal structure or supervi-
fractures was decreased in patients who completed the pro- sion. Of note, this cohort was able to exercise at level of
gram (8). These findings suggest that exercise as an inter- intensity, frequency, and duration known to increase cardio-
vention not only improves function but also may be a factor vascular endurance, using only a local fitness center and a
in preventing subsequent medical complications. heart rate monitor (17).
Although there is limited high-level evidence demon-
strating the role of exercise in promoting neurorecovery Cerebral palsy
after traumatic brain injury (TBI) (34), several small studies A recent review by Lawrence et al. investigated the effect
have shown promise in this regard. A recent pilot study by of exercise on functional mobility in adults with CP (30).
Weinstein et al. (47) engaged subjects with TBI in regular Of the interventions identified, including whole-body vi-
exercise consisting of aerobic exercise over a 12-wk period. bration, treadmill training without body-weight support,
As early as 4 wk into the program, subjects demonstrated rhythmic auditory stimulation, dynamic balance and gait
positive effects on both short-term and long-term mood as activities, progressive resistance training, and interactive
measured by the Profile of Mood States-Short Form. Addi- serious gaming, only rhythmic auditory stimulation and
tional work by Chin et al. (10), using a similar exercise interactive serious gaming demonstrated statistically sig-
protocol, revealed improvements in markers of cognitive nificant benefits with regards to gait and balance, respec-
function, such as the Trail Making Test and Repeatable tively (30). The authors noted that further studies are
Battery for the Assessment of Neuropsychological Status, as needed to better understand the impact of an organized
well as improvements in cardiorespiratoroy fitness (9). exercise intervention on the function of adults with CP
Damiano et al. (15) engaged individuals with TBI in an el- (29). Additionally, recent work has supported the of use of
liptical training program over the course of 8 wk with an accelerometers to measure habitual physical activity in
additional 8-wk follow-up, demonstrating improvements in adults with CP with Gross Motor Function Classification
voluntary and automatic balance reaction performance as System (GMFCS) levels I to V V an important step forward
well as improved scores on the Pittsburgh Sleep Quality toward quantifying physical activity (and thus the effec-
Assessment (PSQI), Hamilton Rating Scale for Depression tiveness of interventions) in this population (12).
(HAM-D), and Hopkins Verbal Learning Test-Revised Recent work has demonstrated several important con-
(HVLT-R). Related to mild TBI, a recent RCT by Kurowski siderations for individuals with CP involved in elite com-
et al. (27) demonstrated that a home aerobic training pro- petitive sport, indicating that considerations related to
gram decreased self-reported postconcussive symptoms in spasticity and reduced neuromuscular control may have
adolescents compared with those who completed a full-body implications performance, however also noting that sport-
stretching program only. specific training may enable the athlete to optimize their
Of great importance, consistent engagement in exercise function when compared with sedentary individuals with
and physical activity often presents a barrier to the popu- CP (39,40). For example, in a sample of six paralympic
lation of individuals with acquired brain injury, potentially athletes with CP, Runciman et al. (40) noted that athletes
due to the confluence of both mobility-related and intel- may elect to maintain conservative pacing strategies due to
lectual disability. A systematic review by Hamilton et al. concern for fatigue, which ultimately may cause a detriment
(20) assessed the factors associated with decreased physical to performance. Additionally, in a small sample of athletes
activity levels in adults with TBI, noting that multiple, with hemiplegic CP, bone mineral density was noted to be
complex factors present barriers to exercise. Most promi- similar between the affected and nonaffected side, although
nent were barriers related to psychological health (e.g., de- fat-free soft tissue mass was significantly lower on the side
creased exercise self-efficacy, increased depression, frequency affected by hemiplegia (39).
of cognitive symptoms, increased self-consciousness), physi-
cal health (e.g., use of a ambulatory device, increased pain, Intellectual disability
increased fatigue), and the environment (e.g., lack of exercise In addition to individual factors that may influence par-
facilities, lack of transportation, lack of social support), ticipation in exercise, social factors, such as family concerns,
among others (20). Additionally, one recent survey study of also can play a role in determining activity participation in
physical therapists determined that they do not always pro- individuals with Down syndrome. Alesi and Pepi (2) investi-
vide education about community-based exercise programs to gated this issue in the parents of young people with Down
their patients with stroke, and barriers to education include syndrome, determining that parental beliefs are a major

270 Volume 16 & Number 4 & July/August 2017 Prescribing Exercise to Individuals with Disabilities

Copyright © 2017 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
barrier contributing to reduced physical activity engage- prevent and treat the potential detriments of prolonged heat
ment this cohort. Additional barriers identified were a lack exposure (44). In individuals with SCI who have a high-
of expert instructors and coaches, as well as characteristics level injury, there may be a loss of thermoregulatory control
specific to Down syndrome, such as motor impairments, from the hypothalamus via the sympathetic nervous system
hypotonia, cardiac abnormalities, and coordination diffi- (7). The environmental stimuli of heat and cold and the
culties. In a retrospective study, Lawson and Foster (31) compensatory signals of sweating and shivering, for exam-
sought to evaluate the relationships between sensory pat- ple, cannot be transmitted past the level of the injury; there-
terns, obesity, and physical activity engagement of children fore, individuals lose their ability to autoregulate temperature
with autism, many of whom were overweight or obese. The (7). This creates a condition called poikilothermia in which
authors determined that children with sensory avoiding individuals with SCI have higher body temperatures in warm
behavior patterns had higher BMI; conversely, children environments and lower temperatures in cold environments
with sensory seeking behaviors participated in a greater (7). As a result, proper heating and cooling strategies also
numbers of formal and informal physical activities (31). should be implemented and reinforced for this population (7).
Additionally, results indicated that children with higher
BMI participated in fewer activities than those with lower Risk of low-energy fracture due to osteoporosis
BMI (31). Osteoporosis may affect a wide range of individuals, and
many factors may contribute, such as age, sex, nutritional
Safety Principles to Note When Prescribing Exercise to status, immobility, sedentary lifestyle, and/or a variety of
Individuals With Disabilities medical conditions. Individuals with disabilities that cause
Although the potential detrimental health impacts of prolonged immobility, particularly those with reduced
sedentary lifestyles in individuals with disabilities is pro- weight-bearing status, such as daily wheelchair users, are at
found, it is important to note several factors that must be risk for severe osteoporosis. Often, this may go undiagnosed
considered before safely prescribing exercise. When keeping until a fracture occurs (45). Fractures can occur even in rel-
this in mind, both the initiation and maintenance of exercise atively benign settings, such as ground-level falls and minor
have the maximum potential to benefit and empower the in- traumas (45). In individuals with SCI, falls from a wheelchair
dividual while minimizing risk of secondary conditions and and transfers are the most common cause of fracture (4).
unnecessary comorbidity. For easy reference, the most clini- Athletes with disabilities may be at particularly high risk
cally relevant potential health considerations are listed here. when involved in high-speed sports, such as alpine skiing,
handcycling, and wheelchair racing. Management of osteo-
Autonomic dysreflexia porosis in at-risk individuals should occur via a multifaceted
Autonomic dysreflexia (AD) is a condition impacting in- approach including optimizing nutrition, weight-bearing ex-
dividuals with SCI, typically at or above the level of T6. AD ercise (when possible), and close physician follow up with
occurs when a noxious stimulus below the level of injury consideration of pharmacotherapy (45).
incites a reflex sympathic surge with rapid increases in cir-
culating epinephrine and norepinephrine. In individuals Skin breakdown
with SCI, this reflex response goes unchecked due to lack of In both active and sedentary individuals with disability,
central neuroinhibitory control from the brain. The most prolonged immobility and reduced cutaneous sensation can
common cause of AD is a distended urinary bladder (26). lead to skin breakdown for a variety of reasons. Individuals
Due to the sympathetic surge, individuals may experience a with decreased mobility V such as those with SCI, TBI, or
hypertensive emergency, in addition to flushing, piloerection, stroke V are at increased risk for pressure ulcers over bony
headache, and agitated behavior. When untreated, AD can be prominences as a result of ischemia from capillary bed oc-
fatal due to acute hypertension resulting in cerebral hemor- clusion, which may not be detected in insensate regions (7).
rhage, seizure, or myocardial infarction (46). Initial treatment Individuals involved in sports and exercise may be at even
consists of reversing the source of noxious stimulus, such as higher risk when using tightly-fitting sports equipment and
emptying the urinary bladder through catheterization. In when the skin become moist due to sweating. Additionally,
some cases, elite athletes with SCI have been known to pur- amputees who use sports prosthesis may experience skin-
posefully induce AD to enhance performance (46). This related illness in the stump-socket interface (25). Adequate
process is strictly prohibited by the International Paralympic skin care is integral in these individuals. Appropriate posi-
Committee, and strongly discouraged in all athletes due to tioning, support surfaces, such as pressure relief cushions on
the potential health risks. wheelchairs, optimal fitting of prosthesis, and skin hygiene,
should all be used to prevent skin breakdown. However, in
Impaired thermoregulation the instances where skin breakdown does occur, additional
Individuals with neurologic injury may experience diffi- management may include local debridement and wound
culty with temperature regulation, impacting tolerance to care, protective dressings, adequate nutrition with increased
exercise. For example, in MS, there is a well-known symp- protein intake to stimulate tissue healing, and antibiotics as
tom of heat intolerance due to advanced demyelination of indicated (7).
the thermoregulatory conduction pathways (44). These in-
dividuals may experience a worsening of their physical and Musculoskeletal pain
cognitive symptoms after exposure to heat. In certain in- Musculoskeletal pain can be a sequela of many different
stances, these symptoms may be permanent (44). Thus, in- conditions in individuals with disabilities and can often be
dividuals with MS should be counseled about how to exacerbated with exercise. For example, individuals who

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are wheelchair users for their daily function as well as for prescription can be made accessible to all, thus improving
sports activities may experience upper extremity overuse health outcomes for individuals of all abilities.
injuries, which may impact both sport performance as well
as daily functioning (7). In elite athletes with disabilities, Funding provided by Kelley Adaptive Sports Research
musculoskeletal injuries to the upper extremity are seen most Institute. The authors declare no conflict of interest.
commonly across all disability types (49). For this reason,
shoulder injury prevention programs are extremely impor-
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