Critical Reviews™ in Physical & Rehabilitation Medicine, 31(1):43–51 (2019)

Level of Sports Participation and Performance

among People with Spinal Cord Injury
Oshin Amberkar, Bela Agarwal, Yuvraj Singh,* Ruturaj Shete, &
Rajani Mullerpatan
MGM School of Physiotherapy, Mahatma Gandhi Mission Institute of Health Sciences, Navi
Mumbai, India
*Address all correspondence to: Yuvraj Singh, Assistant Professor, MGM School of Physiotherapy, Mahatma Gandhi
Mission Institute of Health Sciences, MGM Educational Complex, Sector 1, Kamothe Navi Mumbai, 410209,
Maharashtra, India, E-mail: [email protected]

ABSTRACT: Sports participation in people with spinal cord injury leads to enhanced functional
capacity, increased muscle strength, greater flexibility, and increased optimism. It is important
to encourage people with spinal cord injury to participate in sports and understand facilitators of
and barriers to it. Sports participation in people with physical disabilities including spinal cord
injury is lower compared with people without them. Sports participation among the physically
disabled in high-income countries like the United States and the Netherlands is 44% and 37%, re-
spectively, whereas among people with spinal cord injury in Australia and Switzerland it is 44.6%
and 59.8%, respectively. Limited information is available on sports participation of people with
spinal cord injury in low- to middle-income countries. The present study aimed to explore sports
participation among adults with spinal cord injury in Mumbai, India. Following ethical approval,
102 subjects (mean age 40.41 years; 88 males and 14 females) with spinal cord injury from four
paraplegic rehabilitation centers were interviewed. Sports participation was 60% in people with
spinal cord injury (n = 61/102). Strong family support, financial security, and institutional support
in the form of motivation and training facilities were the top facilitators. Barriers faced during
participation in sports were difficulty in reaching the sports ground, lack of disabled-friendly
toilets, and accommodation. Reasons for not participating in sports were lack of self-motivation,
poor fitness level, and low confidence attributed to disability.

KEY WORDS: sports participation, spinal cord injury, paraplegic sports

I. INTRODUCTION

Spinal cord injury (SCI) results in temporary or permanent functional loss. Due to loss
of motor, sensory, and/or autonomic innervations below the level of injury, it is likely for
persons with spinal cord injury to develop an inactive lifestyle, which negatively influ-
ences physical fitness, social participation, and quality of life.1 Furthermore, inactivity is
associated with increased risk of developing secondary health problems, such as cardio-
vascular diseases, obesity, and non-insulin-dependent diabetes mellitus.2
People with SCI are advised to participate in sports as a therapeutic tool to overcome
health complications and prevent secondary disabilities, thus making it a vital component
of rehabilitation.3 Review of the literature suggests improvement in levels of physical
health and well-being, self-confidence, social awareness, self-esteem, vocational success,
incomes, and likelihood of employment following participation in sport.1,2,3

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44 Amberkar et al.

Sport is increasingly being used as a treatment complementing conventional methods

of physiotherapy. It helps to improve strength, coordination, and endurance. Sports such
as weight lifting and archery strengthen the arm muscles of paraplegic patients, enabling
them to gain independence in self-care activities. Wheelchair sports such as basketball
require the disabled person to propel the wheelchair and learn to pass, catch, and inter-
cept the ball, which helps to develop coordination. Swimming is generally believed to
be a valuable form of exercise and treatment, facilitating, among other things, coordina-
tion, endurance, strengthening of back and leg muscles, and weight loss.4,5 In recent years,
along with recognition of the benefits of participation in physical activity, there has been
an immense change in societal perception of persons with disabilities. It has been realized
that the majority of persons with disabilities can have a better quality of life if they have
equal opportunities and effective access to rehabilitation.1,3
One way of appraising sports participation among people with disabilities is to study
the numbers at Paralympics games (Fig. 1). The Paralympics Games of London in 2012
were more widespread than ever, with 2.7 million spectators, surpassing the Paralympics
Games held in Beijing in 2008, with 9,00,000 spectators. In total, 4,237 athletes from 164
countries competed in 20 sports. This compares with 3,951 athletes from 146 countries
in Beijing. With more international awareness of Paralympics sports, one would expect
that the sports participation of people with physical disabilities in general might also in-
crease. Despite the presence of sports in rehabilitation programs and the growing interest
in Paralympics sports, however, the majority of people with physical disabilities still are
not physically active.6
It is a known fact that individuals with SCI in high-income countries like Australia,
Sweden, and the United States have reduced participation in sports and leisure activi-
ties when compared with their able-bodied counterparts.7 In Australia, sports participation

FIG. 1: Indian contingents at Paralympics

Critical Reviews™ in Physical & Rehabilitation Medicine

Sports Participation in People with Spinal Cord Injury 45

among 121 people with SCI (age 16–64 years; paraplegia and quadriplegia) was 44.6%.
Financial stability was the most important factor in taking up opportunities in sports.
A negative association was found between age and sports participation, indicating the
need for special efforts to attract and support sport participation by older individuals with
SCI.1 In Switzerland, sports participation among 505 people with SCI was 59.8%. The
participation rate among women with SCI was 47%, while it was 73% among men. The
rate of participation among paraplegics was 72% while among tetraplegics it was 28%.
Prior to injury, 72.7% of subjects participated in sport at least once a week, decreasing
to 59.8% at the time of the survey. The study showed that sports participation in persons
with SCI significantly decreased after the onset of SCI, particularly in women and persons
with tetraplegia.8
Sports participation was 46.7% among 45 people with SCI in the United Kingdom.9
Participation in sports as well as employment status decreased after injury due to poor
access to sports facilities and to work. Almost 80% of sports participants were males,
stressing the need to encourage females with SCI.9 Likewise, according to a report on
participation in sports by people with disabilities in Ireland, 38% of adults with disabilities
were participating in sports compared with 66% of those without disabilities.10
Sports participation in Deaflympics, Paralympics, and Special Olympics World
Games between 1991 and 2006, encompassing four winter and four summer Games by
low- and medium-income countries (LMIC) increased from 1991 to 2006. However, 23%
of developing countries have never participated in any games during the period of analy-
sis. Female participation is still less than half of total male participation. Oceania was
identified as the region with the least participation historically, followed by Africa and
Asia.11 The level of sports participation among the able-bodied, estimated by the ratio
between the number of members in sports federations and the number of inhabitants, is
sparse in developing countries. The ratio of sports participation in developing countries is
0.01% of the population (compared with 20–25% of the population affiliated with sports
federations in European countries). Additionally, most participants are concentrated in
a few sports, which are predominantly determined by the availability of facilities.12 Al-
though there has been a definite increase in the number of participants, it is not adequate
considering India’s population of more than a 1.35 billion. Also, the participation of fe-
male athletes is a matter of concern.
In a populous country like India, nearly half a million people are living with physi-
cal disabilities. As there is no national registry, it is not possible to predict the number of
people with SCI among them. Studies exploring health and functional status of people
with SCI in India are few. Mathur et al. conducted a cross-sectional study to determine the
epidemiological and neurological status of patients with SCI in Jaipur (Rajasthan) who
were admitted to the district hospital from January 2000 to December 2008.13 Out of 2,716
patients with SCI, 1,400 had cervical injuries and 1,316 had thoraco-lumbar injuries. The
majority of participants were males (2,194/2,716; 80.8%). About 79% of patients were
from rural areas and 21% were from urban areas. Young men in the aged 20–49 years
made up 71% of total participants. Nearly half of these participants lived in nuclear fami-
lies (1,389/2,716; 51.1%), whereas 30.6% (832/2,716) lived in joint families. The average

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46 Amberkar et al.

monthly family income was below INR 3,000 (US$ 60; UK£ 37.5). Mathur et al.’s in-
depth study did not discuss the functional status of people with SCI or their participation
in sports or leisure activities.13
To our knowledge, there have been no attempts made to study sports participation
rates in a country like India. It is also important to look beyond mere numbers and explore
possible facilitators of and barriers to sports participation (Table 1) to aid the design of
appropriate programs to address the issue of sports participation by people with SCI. It is
imperative that sports and recreational facilities be barrier-free and adapted to the needs
of all people equally. Often, most facilities are inaccessible to persons with disabilities
or have no disabled-friendly equipment or trained personnel. The purpose of the current
study was to determine sports participation rate among people with SCI and identify vari-
ous barriers and facilitators influencing sports participation.

II. METHODOLOGY

Approval from the Institutional Ethics Committee (IEC) of MGM Institute of Health Sci-
ences, Navi Mumbai, was sought and obtained. Participants were recruited using con-

TABLE 1: Facilitators of and barriers to sports participation among people with SCI (n = 61)
Facilitators
Num- Percent- 95% confidence
Factors identified
ber age interval
1 Strong family support 58 95.08 86.3–99
2 Financial stability 54 88.52 77.8–95.3
3 Institutional support 51 83.60 71.9–91.8
4 Easy access to sports ground/academy 49 80.32 68.2–89.4
5 Peers playing sports 47 77.04 64.5–86.8
6 Presence of a role model 34 55.73 42.4–68.5
Barriers
1 Difficultly in reaching sports ground/academy 56 91.80 81.9–97.3
2 Lack of disabled-friendly toilets 55 90.16 79.8–96.3
3 Lack of disabled-friendly accommodation 52 85.24 73.8–93
4 Inadequate training facilities 48 78.68 66.3–88.1
5 Inappropriate equipment 45 73.77 60.9–84.2
6 Expense 45 73.77 60.9–84.2
7 Attitude of others 39 63.93 50.6–75.8
8 No teams 36 59.01 45.7–71.4
9 Communication barriers 31 50.81 37.7–63.9
10 No coaches/trainers 23 37.70 25.6–51

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Sports Participation in People with Spinal Cord Injury 47

venient sampling from three paraplegic centers in Mumbai and one in Pune. The three
centers in Mumbai were charitable organizations providing inpatient services, while the
center in Pune provided inpatient rehabilitation for veteran defense personnel suffering
from spinal cord injury. The study included SCI adults who met the criteria of having a
diagnosis of quadriplegia or paraplegia at least one year prior to the survey and voluntarily
agreed to participate in the study.

A. Instrument

Participants were interviewed by a trained physiotherapist with an indigenously devel-

oped semistructured, closed-end questionnaire. The questionnaire, developed after exten-
sive review of the literature and consultation with physiotherapists and other professionals
working with people with SCI,14 collected data regarding involvement in sports. Sports
participation was defined as engaging in sports at least 45 minutes/session, for a minimum
of two days a week. Those who were participating in sports were further asked about per-
ceived facilitators and barriers. Reasons for not participating in sports were asked of the
others. Face validation of the questionnaire was performed based on critical feedback from
three physiotherapy experts (one each from neurophysiotherapy, musculoskeletal sports
physiotherapy, and cardiorespiratory physiotherapy) with minimum experience of 10 years.
An informal, semistructured interview was conducted with three subject matter ex-
perts working in fields involving SCI or other physical disabilities to discuss probable
methods for improving sports participation. These experts included a state-level admin-
istrator of paraplegic games and an ex-Paralympic swimmer, an occupational thera-
pist working exclusively in sports for the disabled for more than 30 years, and a social
worker in a paraplegic home in Mumbai with 25 years of experience. The semistruc-
tured interview was proctored by a senior physiotherapist with 10 years of experience.
Each interview lasted approximately 45 minutes and focused on the experts’ views on
ways to improve sports participation.

B. Data Analysis

Descriptive statistics were used to characterize the study population and to describe SCI
sports participation at the time of the survey. Survey data were analyzed using SPSS ver-
sion 24. Point prevalence and 95% confidence interval (CI) were computed as the propor-
tion of individuals with SCI participating in sports currently divided by the total number
of participants included in the study.

III. RESULTS

The study was conducted among 102 people with SCI residing in four paraplegic rehabilita-
tion centers in Mumbai. They were divided into sport participants and nonparticipants based
on the single-item question. Among the centers, three were in Mumbai; the one in Pune was
a government-aided rehabilitation facility for army veterans suffering from SCI. The total

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48 Amberkar et al.

study population comprised 88 males and 14 females. All army veterans were males and
made up 36% (n = 37) of the total study population. The mean age of the study population
was 37 years (16–64). Among the 102 SCI patients, 90% (n = 92) had thoracolumbar lesion
and 10% (n = 10) had cervical lesion. Average time since injury was 13.39 years.
The sample was divided into sports participants and nonparticipants based on fre-
quency of participation. Sports participation among people with SCI was 60%. The most
common sports activities among SCI adults were outdoor games like basketball, cricket,
throw-ball, wheelchair racing, javelin throw, shot-put, discus throw, and swimming, and
indoor games like carom, chess, and darts.
Of the 61 who were participating in sports, 56 were males (92%) and 5 were females
(8%). The majority of our participants (32/61; 52%) were participating at the national
level and the rest at recreational levels. There were 6 athletes (10%) who had represented
India at the Paralympics games. Sports participation was 60% in SCI adults (n = 61/102).
Strong family support (n = 58/61; 95.08%), financial security (n = 54/61; 88.52%), and
institutional support in the form of motivation and training (n = 51/61; 83.60%) were
reported as the top facilitators. Barriers faced during practice and participation at tourna-
ments were difficultly in reaching the sports ground ( n = 56/61; 91.80%), lack of disabled-
friendly toilets (n = 55/61; 90.16%), and accommodation (n = 52/61; 85.24%). Reasons
for not participating in sports were lack of self-motivation (n = 39/41; 95.1%), poor fitness
level (n = 36/41; 87.80%), and low confidence attributed to disability (n = 35/41; 85.35%).

IV. DISCUSSION

The aim of the study was to determine sports participation among people with SCI and
to gain insight into participation barriers and facilitators. Sports participation was 60%
among the SCI participants in our study, which was conducted in metropolitan rehabilita-
tion centers. The center for army veterans had a mandatory schedule for sports as a part
of the daily routine, resulting in 78% of patients engaging in sports. Of all civilians with
SCI from the remaining centers, 54% were participating in sports. These centers also pro-
moted sports by encouraging participation and providing sports facilities . These were the
reasons for the surprisingly high rate of sports participation found in our study, which was
comparable to rates found among community-dwelling people with SCI in high-income
countries like Australia and Switzerland.1,8
Data gathered from paraplegic rehabilitation centers might not provide a clear picture
of sports participation among the community-dwelling people with SCI in a low- and
medium-income country like India. With almost 66.46% of Indians living in rural areas,
it is important to find sports participation rates in these areas to have a complete picture
regarding the extent of the problem.15
Among the 60% of people with SCI who participated in sports in our study, basketball
was the most popular sport, played by 20% of participants. The other popular sports were
throwball (16%), cricket (14%), and wheelchair racing (10%). In similar studies among
people with SCI in the United Kingdom, the most popular sports were swimming, archery,
weight training, basketball, and table tennis.9,16

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Sports Participation in People with Spinal Cord Injury 49

Top facilitators of engagement in sport were financial security, strong family support,
and institutional support mainly in the form of motivation and training facilities. Foremen
et al. reported financial resources as the most important reason to promote sports among
adults with SCI in Australia.1 Family support was identified as an important facilitator in
other studies.9 Partners and family members can help by providing emotional, functional, or
economical support. It may be that athletes experience support from family as positive be-
cause family can motivate them to continue participation in sports at difficult times. Family
can also help in achieving the right balance between sport and relaxation.3 Lack of access to
facilities like disabled-friendly sports grounds and courts were a major barrier that hindered
participation by our study population. Lack of ramps, modified doors, and disabled-friendly
toilets were reported as chief barriers to sports participation during practice or tournaments.
Other barriers included inadequate training facilities, lack of transportation, and accommo-
dation during sports competitions.3,17 Reasons for nonparticipation (Table 2) included lack
of self-motivation, low confidence and poor fitness level. Similar findings were reported in
interviews conducted by Datillo et al. when exploring barriers to sports participation in the
United States.18 Results from our study indicate that motivation from family and primary
care givers is essential in encouraging a person with SCI to take up sports.
The results of this study indicate a surprisingly high level of sports participation ow-
ing to the inclusion of institution-based SCI, community dwellers, and army veterans.
Barriers to sports participation were mainly extrinsic, while facilitators were mainly in-
trinsic. These findings support the findings of Jaarsma et al., who explored sports partici-
pation barriers and facilitators facing people with different types of physical disabilities
in the Netherlands. 7
We interviewed three experts in the field: a state-level administrator of paraplegic
games, an ex-Paralympics swimmer, an occupational therapist working exclusively in

TABLE 2: Reasons for not participating in sports or leisure activities (n = 41)

95% confidence
Reason Number Percentage
interval
1 I am not motivated to participate 39 95.1 83.5–99.4
2 I am not fit enough 36 87.80 73.8–95.9
3 Due to my disability 35 85.35 70.8–94.4
4 I don’t enjoy sport 34 82.92 67.9–92.8
5 No access to facilities 32 78.04 62.4–89.4
6 I have no time 30 73.17 57.1–85.8
7 It is too expensive 29 70.73 54.5–83.9
8 I don’t have a personal assistant 27 65.85 49.4–79.9
9 None of my friends play sports 25 60.97 44.5–75.8
10 I have no transportation 22 53.65 37.4–69.3
11 I don’t know where to go 18 43.90 28.5–60.3

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50 Amberkar et al.

sports for the disabled for more than 30 years, and a social worker in a paraplegic home
with 25 years of experience. All were knowledgeable about overcoming the barriers to
sports participation outlined here. The experts stressed free access to state-funded sports
facilities, availability of coaches for Paralympics sports at these facilities, and disabled-
friendly public transportation as primary solutions. Building up confidence levels and
encouraging people with SCI in institutions and in the community by creating more aware-
ness and motivational programs are important. The experts reiterated the need for private-
public partnerships to fund such initiatives so that finances are not a barrier to participation.
There have been increasing attempts by state and central governments in India to
tackle the problems of sports participation by the disabled by opening up playing fields in
urban areas, making them accessible to the disabled, and providing pensions to Paralym-
pics athletes.19 Much work is still required to ensure that the advantages of such schemes
reach those with SCI living even in the remotest part of the country.
Our results need to be interpreted with some caution considering the limitations of the
study methodology. The selection of an accessible sample of patients in paraplegic reha-
bilitation centers, who are probably more active in general, may limit the generalizability
of our findings. A community-level survey among people with SCI would give a better
picture of general participation levels and the approach of family and caregivers toward
sports participation among people with SCI.

V. CONCLUSION

Sports participation in people with SCI was lower compared with that of their able-bodied
counterparts in developing countries. Despite the growing popularity of parasports, par-
ticipation among the physically disabled at international levels such as the Paralympics is
still inadequate. There is a clear paucity of literature on sports participation among people
with SCI in low- to middle-income countries. The current study, conducted in four ur-
ban paraplegic centers in India showed 60% sports participation among people with SCI.
Strong family support and financial security were the main facilitators of participation,
while difficulty in reaching the sports ground and lack of disabled-friendly toilets and ac-
commodation were the top barriers. Among the 40% of people with SCI not participating
in sports or leisure activities, the top reasons for the lack of participation were lack of self-
motivation, poor fitness level, and low confidence attributed to disability.

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