INTRODUCTION
Spinal cord injury (SCI) is associated with complex needs, and requires multidimensional and long-term rehabilitation interventions. The World Health Organization (WHO) estimates that globally, approximately 15.4 million people were living with SCI in 20211. A recent systematic review places the global annual incidence between 10 and 83 cases per million people, with estimates ranging from 250 000 to 500 000 new cases per year. Other projections suggest even higher figures, up to 700 000 to 1.2 million new SCI events annually, though these may include partial injuries and non-traumatic causes2.
Sport has historically played a key rehabilitative role for such injuries. Long before becoming a global symbol of elite sports performance and empowerment, the Paralympic initiative was rooted in rehabilitation: sport was introduced as a clinical intervention to support the physical recovery, psychological resilience, and social reintegration of individuals with SCI3–5. Indeed, the health benefits are well documented. Adaptive and recreational sports are associated with improved cardiovascular health, muscular endurance, and functional mobility, including transfers and wheelchair use; in addition, by improving circulation and providing regular physical activity, they also help prevent secondary complications such as pressure ulcers and urinary tract infections. Beyond the physical benefits, sports engagement facilitates social reintegration, promotes a renewed sense of identity, and supports participation in educational, vocational, and community roles. When included in rehabilitation programs, recreational sports contribute to physical recovery, while also improving quality of life, maintaining functional independence, and counteracting the consequences of sedentary behavior6–8. Among people living with SCI, participation in sport is associated with reduced depressive symptoms, improved body image, greater life satisfaction, increased likelihood of returning to education or employment, and reduced healthcare service use9,10. These findings underline the comprehensive impact of sports participation across health domains11–14.
Despite this robust evidence, access to sport remains limited for many people with SCI9,15,16, and most do not engage in regular physical activity. This is frequently due to the absence of structured and inclusive entry pathways. Rehabilitation services often overlook sport as a core therapeutic intervention, and the limited existing opportunities tend to target individuals who are already physically active or oriented toward elite competition. This trend is reinforced by the evolution of the Paralympic movement into a high-performance sports system. In recent decades, the Paralympic movement has reshaped global perceptions of disability by highlighting the athletic capabilities of persons with impairments and promoting their visibility on the international stage17. While this development has contributed to the recognition of athletic excellence, it has also distanced the Games from their inclusive and therapeutic origins. As a result, access to sport remains limited for many people with SCI who are not pursuing competitive careers but could benefit from sport as a component of rehabilitation.
This situation highlights a substantial implementation gap. While literature confirms the positive effects of sport participation, it provides little guidance on how to incorporate sport early in the recovery process or how to support sustained participation among non-athletes18–20. Without a structured support system, barriers such as limited facility access, lack of trained personnel, financial constraints and social stigma often reduce engagement9,15. Translating evidence into practice requires well-designed, accessible, and replicable sport initiation programs tailored to the specific needs of people with SCI. These programs should not only lower access barriers but also actively promote engagement, motivation and functional improvements. This need to integrate sport within the continuum of care has been reinforced by recent studies demonstrating that community-based and structured programs can improve cardiovascular fitness, functional mobility, and psychological outcomes. Clinical guidelines now recognize adaptive sport and exercise as essential components of secondary prevention, quality of life promotion, and long-term self-management for this population21–26.
In response to this implementation gap, the present study aims to evaluate the effectiveness of a structured sports initiation program specifically designed for people with SCI. Using a quasi-experimental pre-post test design, the study will assess the impact of the program on quality of life, satisfaction, and self-efficacy in activities of daily living. By systematically introducing sport as a rehabilitative resource, the intervention seeks to provide an inclusive and replicable model that supports longterm recovery, autonomy, and participation beyond the clinical setting.
METHODS
Study Design
This study employed a quasi-experimental, single-group pre-post design to explore the short-term effects of a functional sports initiation program for people with SCI. The design allowed for the observation of changes across multiple outcome domains, using validated measures administered before and after the intervention. The study was conducted in an ecological setting, with procedures aligned to ethical standards. All procedures were performed in accordance with the ethics standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. Ethics committee approval was obtained from Sapienza University of Rome (Prot. 0969/2023).
Participants
The participants were recruited by convenience sampling from an Italian spinal unit (Orthopedic Trauma Center [CTO] Andrea Alesini, Rome). The following inclusion criteria were applied: (1) age ≥ 18 years, (2) diagnosis of SCI between C4 and L1 level, and (3) expressed interest in initiating sports activity. Both individuals with no prior sports experience and those with a history of recreational or competitive participation were eligible, provided they were not currently involved in structured sports programs at the time of recruitment; this criterion was introduced to avoid confounding effects related to ongoing physical conditioning or advanced psychological adaptation to sport. The exclusion criteria comprised refusal or inability to provide informed consent, a diagnosed psychiatric disorder, or clinically-assessed cognitive impairment. All eligible participants received detailed information about the study aims and procedures, and written informed consent was obtained prior to participation.
Characterization of the sports initiation program
The intervention was developed through a participatory, interdisciplinary process involving professionals from the CTO spinal unit in Rome and the Tre Fontane Paralympic Preparation Center. The team included a physiatrist, a physiotherapist, an occupational therapist, and a Paralympic coach, all with prior experience in Paralympic sports. The logistical planning and final selection of sports were guided by a feasibility assessment of the Tre Fontane facilities which considered their clinical relevance, and the availability of trained staff and accessible infrastructure.
The program included Para athletics (including wheelchair racing and seated throws), Para swimming, wheelchair fencing, wheelchair tennis, Para archery, and boccia. In addition the criteria above, their inclusion was also supported by their widespread presence in urban rehabilitation settings and their alignment with established Paralympic development pathways. Furthermore, as these sports include some of the most commonly-implemented adaptive disciplines, both nationally and internationally, their inclusion enhances the external validity and scalability of intervention, and increases the feasibility of replication in comparable clinical or community-based contexts. Moreover, they have been consistently demonstrated to have positive effects on functional performance, cardiovascular fitness, and psychosocial outcomes in individuals with SCI 27–29.
Each Paralympic sport engages distinct motor domains, thus contributing to the development of specific neuromotor and physical capacities. Para swimming facilitates aerobic conditioning and may reduce spasticity by promoting symmetrical and rhythmic movements in a gravity-reduced environment30,31. Wheelchair fencing and para archery enhance upper limb coordination, precision, and postural control, while also requiring sustained attentional focus and visuomotor integration29. Boccia primarily supports fine motor planning and trunk stability, with additional cognitive demands related to strategy and target accuracy. Para athletics and wheelchair tennis improve muscular strength, dynamic balance, and agility through repetitive, high-intensity movements and directional changes. This diversity was intended to expose participants to a broad spectrum of physical demands, fostering engagement and enabling individualized adaptation without reliance on a fixed progression scheme29,32.
During a 14-week period, the participants had the opportunity to experiment with six different sports. The program was structured into two consecutive seven-week phases. In the first phase, participants engaged in Para swimming, Para athletics, and Boccia; in the second phase, they practiced Para archery, wheelchair tennis, and wheelchair fencing33–35. Each sport was practiced twice per week, with each session lasting two hours, totaling six hours of activity per week.
Each two-hour session followed a structured format designed to ensure safety and skill acquisition. Sessions began with a 20-minute warm-up phase, including joint mobilization, stretching, and cardiorespiratory activation tailored to the participants’ injury level. This was followed by approximately 30–40 minutes of technical instruction, during which participants learned sport-specific movements and rules, with adaptations when needed (e.g., seated techniques, grip modifications, use of assistive devices). The core of the session, approximately 40–50 minutes, was dedicated to guided practice under the supervision of Paralympic coaches, with one-on-one adjustments and progressive intensity. The final 10–15 minutes were reserved for cool-down activities and group reflection, where participants could share feedback, discuss perceived difficulties, and set short-term goals for subsequent sessions. This structure was consistent across sports to promote familiarity and psychological safety, while still allowing each discipline to express its specific rehabilitative potential (e.g., aerobic activation in swimming, proprioceptive challenge in fencing, fine motor control in archery). All participants rotated through the sports in a fixed schedule designed to ensure exposure to all disciplines while allowing progressive familiarization and adaptation. Although session frequency and duration remained constant, progressive intensity was achieved through gradual increases in task complexity, active participation time, and motor demands tailored to each discipline. This progression was clinically guided and based on therapist observation of individual performance, fatigue signs, and perceived exertion reported informally by participants during sessions.
The questionnaires were completed independently by participants and collected through a self-reporting method. They were distributed and collected by an occupational therapist to ensure consistency. The assessments were conducted in person, primarily at the participant’s home, providing a comfortable and familiar environment that may have contributed to more accurate and reflective responses. However, the Trunk Control Test was administered at the hospital by a clinician to ensure proper evaluation and reliability. All clinicians involved in the administration of the Trunk Control Test received standardized training by a senior physiotherapist with expertise in SCI rehabilitation; this training included joint scoring sessions and consensus meetings to ensure uniform interpretation of test items.
The selection of outcome measures was guided by their specificity for individuals with SCI, their relevance to the ICF domains of activity and participation, and their feasibility for administration within the community setting. Although this specific sports program has not been tested in prior studies, the selected variables represent key constructs associated with autonomy, physical confidence, and health-related quality of life in SCI rehabilitation.
Instruments
The outcome measures were determined at T0 (baseline) and T1, 14 weeks after the start of the sports program.
The Trunk Control Test for Spinal Cord Injury (TCT)36–38 is designed to evaluate trunk control in individuals with SCI, assessing both static and dynamic components of trunk stability. Static control is measured through three items that evaluate the ability to maintain a seated posture for 10 seconds under different lower limb positions. Dynamic control is assessed in two domains: (1) control during trunk movements, consisting of four items evaluating posture maintenance while flexing the trunk in sitting and supine positions or during rolling; and (2) control during upper limb tasks, comprising six items that assess the ability to maintain a seated posture while performing reaching movements in various directions. Scores range from 0 (unable to perform any task) to 24 (optimal performance on all items). The typical administration time is approximately eight minutes. The TCT has demonstrated good inter-rater reliability (ICC > 0.85) and sound construct validity in populations with SCI.
The Spinal Cord Independence Measure III Self Report (SCIM)39 is a validated tool specifically designed to assess functional independence in individuals with SCI, focusing on activities of daily living (ADL). It consists of 19 items grouped into three subscales: Self-care, Respiration and Sphincter Management, and Mobility. Scores range from 0 to 100, with higher scores indicating greater levels of functional independence. The SCIM-SR has demonstrated excellent internal consistency (Cronbach’s alpha > 0.90) and high test-retest reliability (ICC > 0.85). The Italian version has been cross-culturally adapted and validated for clinical use. The typical time required for completion is approximately 10 to 15 minutes, depending on the respondent’s functional status.
The Short Form Health Survey 36 (SF-36)40 is a self-administered questionnaire aimed at quantifying self-perception of health; the questionnaire consists of 36 items organized into the following eight subscales: physical functioning (10 items), limitations due to physical health (four items), limitations due to emotional problems (three items), energy and fatigue (four items), emotional well-being (five items), social activities (two items), pain (two items), perceived general health (five items). The responses for all items are given on a Likert scale, but with a variable and weighted score for each item. Each item is recorded according to a specific calculation. The aggregate scores for each domain range from 0 to 100 and are given as a percentage, where a higher score indicates a more favorable health status. Each of the eight summed scores is transformed linearly on a scale from 0 (negative health) to 100 (positive health) to provide a score for each subscale, which can be used independently. The Italian version of the SF-36 has been widely validated across various clinical populations, including individuals with physical disabilities, and demonstrates high reliability and discriminant validity.
The Moorong Self Efficacy Scale41 is a self-administered questionnaire measuring self-efficacy in people with SCI. The tool is divided into 16 items and composed of two subscales measuring daily activities (items 1, 2, 3, 5, 6, 8, 11, 12, 16) and social functioning (items 4, 7, 9, 10, 12, 14, 15). The respondent completes the questionnaire by assigning each of the 16 items a rating between “really insecure,” corresponding to a score of 1, and “secure,” corresponding to a score of 7, regarding different daily activities and social functioning. Therefore, the total Activities of Daily Living (ADLs) score ranges from is 8 (truly insecure) to 56 (safe), while the social functioning scale ranges form 7 (truly insecure) to 56 (safe). Social functioning ranges from 7 (truly insecure) to 49 (secure). The minimum total score is 15 (truly insecure), while the maximum total score is 105 (secure). The scale is validated for people with SCI and has been shown to have high internal consistency and construct validity. The Italian version has been used in previous research, demonstrating good psychometric properties.
The Wheelchair Use Confidence Scale for Manual users (WheelCon-M)42 is a self-administered outcome measure designed to assess an individual’s confidence in using a manual wheelchair. The person is asked to read the instructions and complete the two sections: Physical Environment Management and Social Environment Management. Each item is rated on a scale from 1 to 10, reflecting the individual’s current perceived level of safety when performing the described activity. The Physical Environment Management section includes three items, while the Social Environment Management section contains eight. Each section yields a partial score based on the sum of the item scores, and the two partial scores are then combined to produce a total score, with a maximum possible value of 200. The WheelCon-M has demonstrated good construct validity and test-retest reliability in individuals with spinal cord injury (SCI). A pilot validation of the Italian short form has been completed, and it has been used in both clinical and research settings.
Statistical Analysis
Statistical analysis was performed using IBM-SPSS version 23.00 software43. Prior to the main analysis, the assumption of normality was assessed using the Shapiro-Wilk test for each variable at baseline (T0) and post-intervention (T1)44. As the data was not normally distributed and ordinal in nature, they were analyzed using the non-parametric Wilcoxon test. Significance was indicated by a p-value less than or equal to 0.05. In addition to p-values, effect sizes were calculated to evaluate the magnitude of observed changes and their potential clinical relevance. For each comparison, Cohen’s d was derived using standard methods adapted for non-parametric data. Effect sizes were interpreted as small (d ≈ 0.2), moderate (d ≈ 0.5), or large (d ≥ 0.8), in accordance with conventional benchmarks45.
RESULTS
The participant group included 15 people with chronic SCI, of whom twelve (80%) were male and three (20%) were female. The most common lesion level was between D3 and D9 (66.8%), while other lesion levels were less frequent, each accounting for 6.7% of the sample. According to the American Spinal Injury Association (ASIA) Impairment Scale (AIS)46, 46.7% of participants had a complete SCI (AIS A), while 33.3% had an incomplete injury classified as AIS D. The majority (80%) used a manual wheelchair, while smaller proportions relied on a powered wheelchair (6.7%), crutches (6.7%), or no assistive device (6.7%). All participants had chronic SCI, defined as more than one year post-injury47. The demographic characteristics of the population are reported in Table 1.
Table 1
Demographic characteristics of the 15 included participants
| Parameter | Frequency (%) |
|---|---|
| Sex ratio – female: male | 3 (20%): 12 (80%) |
| Lesion levela | |
| C4 | 1 (6.7%) |
| D3–D9 | 10 (66.8%) |
| D11 | 1 (6.7%) |
| L1 | 1 (6.7%) |
| L2 | 1 (6.7%) |
| T1 | 1 (6.7%) |
| AISb | |
| A | 7 (46.7%) |
| B | 2 (13.3%) |
| C | 1 (6.7%) |
| D | 5 (33.3%) |
| Chronic/Acute SCIc | Chronic SCI (15; 100%) |
The outcome scores at baseline (T0) and post-intervention (T1) are compared in Table 2.
Table 2
Wilcoxon’s Rank Test between T0 and T1, i.e. after 14 weeks of administered outcome measures
[i] MSES- Moorong Self-Efficacy Scale, n.c.- not calculated (the effect size could not be computed due to a lack of variation in pre- and post-intervention scores), SCIM- Spinal Cord Independence Measure, SF-36- Short Form-36 Health Survey, TCT- Trunk Control Test, WheelCon-M- Wheelchair Use Confidence Scale, p < 0.05 indicates statistical significance
No significant differences were found between T0 and T1 with regard to TCT score, even though the mean values suggested a clinically-relevant improvement in static balance, dynamic balance, and total score. For the SCIM, significant improvements were observed in two out of the three subscales and in the total score; however, despite the positive trend, the effect sizes were small (d ≈ –0.10), suggesting a limited clinical impact. The WheelCon-M also indicated significant improvements across all subscales and in the total score, which yielded a large effect size (d = –0.956), suggesting a substantial gain in perceived control and self-management in wheelchair use.
Furthermore, significant improvements were noted in all SF-36 subscales; particularly the Physical Functioning, Emotional Well-being, and General Health domains (all p = 0.002), and the Energy/Fatigue domain (p = 0.006). Both the Energy/Fatigue (d = –0.846) and Pain (d = –0.800) subscales showed large effect sizes, supporting the clinical relevance of the observed changes. Regarding the MSES, clear and statistically-significant improvements were reported in all subscales (p = 0.001) and in the total score; the Daily Life subscale showed a large effect size (d = 0.981), confirming a clinically-significant improvement.
DISCUSSION
This study aimed to evaluate the effectiveness of a sports initiation program in people with SCI through improvements in trunk control, quality of life, self-perception of health, satisfaction, and self-efficacy in activities of daily living. Given the non-normal distribution of the data, as confirmed by the Shapiro–Wilk test, pre-post differences were analyzed using Wilcoxon’s signed-rank test. Effect sizes (Cohen’s d) were also calculated to estimate the magnitude of the observed changes.
Following the 14-week program, the 15 involved participants showed clinical improvements in all of the observed areas, with significant improvements noted between the baseline and follow-up for most outcome measures. However, no significant change was noted for the TCT score; this result may reflect a ceiling effect, as participants presented relatively high baseline scores, with mean total score of 17.47 (SD = 6.84) out of a maximum of 24. This suggests that most participants had already achieved a considerable level of trunk control at the beginning of the intervention, possibly due to their functional status and the fact that the individuals were included during the chronic phase of SCI. In such cases, when postural function has already reached high levels of control, standard sports-based training may be insufficient to generate further measurable gains. In fact, recent literature suggests that targeted neurotherapeutic strategies (e.g. biofeedback and task-specific training) can enhance trunk muscle activation and postural stability even in the chronic phase of SCI48,49.
For the SCIM, the lack of significance in the Sphincter-Breathing sub-scale (p = 0.07) might suggest that, while the sport program was able to improve functional aspects (e.g. Self-Care and Mobility sub-scales), it did not have an effective impact on autonomic functions. Previous research indicates that rehabilitative intervention of autonomic dysfunction in SCI may require the integration of neurophysiological approaches, rather than relying solely on voluntary physical activity50–52.
Significant improvements were noted in the WheelCon-M scores, which might suggest that sports program positively influenced perceived control and integration in daily life. Although all involved sports were individual disciplines, training was conducted in small groups, allowing participants to interact, share experiences, and receive peer support. Previous studies have shown that such social dynamics, common in both team sports and group-based individual training, can enhance self-efficacy and foster greater confidence in wheelchair use53–55. These findings are also consistent with the fact that the improvements obtained in the SF-36 were both statistically and clinically significant.
The sports program appeared to positively influence the overall well-being of the participants, with a particularly relevant change in the Pain sub-scale. This is in line with existing literature suggesting that regular physical activity can mitigate neuropathic pain in individuals with SCI, with regard to a reduction in pain intensity, improved pain tolerance and decreased pain interference with daily activities56. Training also appears to have had a positive effect on daily activities, as highlighted by the significant improvements obtained on the MSES scores; this reinforces the idea that structured engagement in sport may enhance confidence in managing everyday tasks and social roles.
LIMITATIONS OF THE STUDY
Despite the promising findings, this study has several limitations. The sample size was relatively small (n = 15), which may limit the generalizability of the results to the broader population of people with SCI. Additionally, the sample was composed entirely of people with chronic SCI, preventing direct comparisons with those in the acute or subacute phases. Another limitation is the lack of a control group, which makes it difficult to attribute improvements solely to the sports initiation program rather than other external factors. Furthermoe, no qualitative data was collected. Although the program appeared to be well tolerated and completed by all participants, no interviews or open-ended assessments were conducted to explore participants’ subjective experiences.
The latter aspect should be addressed by future studies including semi-structured interviews or qualitative methods (e.g., thematic analysis) to better support clinical decision-making; these can provide a greater insight into perceived benefits, barriers, and satisfaction of participants. Additionally, long-term follow-up studies would be valuable in assessing the sustainability of the observed benefits and whether continued participation in sports leads to further functional and psychosocial improvements. Finally, exploring the impact of different types of sports and individualized training protocols could help refine and optimize sports initiation programs for people with SCI.
CONCLUSIONS
The study provides a comprehensive analysis of a structured sports initiation program for people with chronic SCI—an area still underexplored in the literature. While most studies have focused on long-term athletes, our findings show that even short-term, guided participation can improve pain, fatigue, and self-efficacy. The outcomes were found to have good effect sizes, which supports the clinical relevance of sport as a therapeutic resource within rehabilitation pathways. The use of a multidisciplinary team ensured that the intervention was personalized and feasible in real-world contexts. Further research should explore the long-term effects of such interventions, include qualitative feedback from participants, and identify the program features which best support sustained engagement.
