Sports for Individuals with Spinal Cord Injury

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Introduction

The perception of ‘Sport’ and what it actually constitutes have been continually debated for decades with many definitions and concepts emerging over the years. The Council of Europe’s European Sports Charter (2001, Article 2, p.3) defines sport as “all forms of physical activity, which, through casual or organised participation, aim at expressing or improving physical fitness and mental well-being, forming social relationships or obtaining results in competition at all levels”.  In the Irish Department of Education’s Sport Strategic Plan ‘Targeting Sporting for Change in Ireland - Sport in Ireland 1997 to 2006 and Beyond , they built on this definition in order to clarify the interpretation under three broad categories;

Recreational Sport; An overriding emphasis on the social and health aspects of sport, with fun and friendship being ‘key components’.

Performance Sport; More structured programs that incorporate some form of competition. Usually organised around school or club structures, with ongoing coaching and involvement in competition from local to national level. Participants at this level are normally required to meet minimal standards of performance and are subject to the rules of the competition.

High Performance Sport; Elite level sport that is highly structured with performance measured against national and international standards. This level of participation requires both internal and external qualities, which are the ability to excel at a personal level as well as on an objective level. The athlete shows a desire for achievement, to prove themselves, reach their own personal limits but also maintain high performance standards.

Sport as a Fundamental Right

“Sport and human rights have always been interconnected, particularly where societies reputation or national pride were at stake” (Corbett 2006, p.30)
As sport has always been an integral part of society, similar limitations and exclusions have been imposed on the participation of men and women with a disability (DePauw & Gavron 2005). This was namely due to the myth that sport, being representative of physical prowess, could not include those who had a physical impairment (DePauw & Gavron 2005). The World Health Organisation endorsed the concept that health and functional ability can be influenced through physical activity and sport as a daily component of everyday life for all individuals including those with a disability. But the acknowledgement of the rights of people with a disability, particularly in sport, has been a slow process and has only evolved in response to changes in societal attitudes and behaviour but the trend today is one of more progressive inclusion and acceptance (DePauw 1992, DePauw & Gavron 2005). 

The adoption of the Convention on the Rights of Persons with Disabilities represented a fundamental step in ensuring the rights of people with a disability worldwide were recognised and put into practice (UN 2008a, UN 2008c). Adopted by the General Assembly in December 2006, the Convention was one of the fastest treaties ever negotiated at the United Nations (UN 2008c). The convention is intended as a human rights instrument with an explicit, social development dimension (UN 2008e). As a human rights treaty it has obligations that are legally binding providing a legal framework to ensure people with a disability can access their fundamental human rights, one of which is the right to take part in cultural life, including participation in play, recreational, leisure and sporting activities, on an equal basis with others (UN 2008e). 

United Nations Convention on the Rights of Persons with Disabilities; Article 30.5

With a view to enabling persons with disabilities to participate on an equal basis with others in recreational, leisure and sporting activities, States Parties shall take appropriate measures:

  1. To encourage and promote the participation, to the fullest extent possible, of persons with disabilities in mainstream sporting activities at all levels; 
  2. To ensure that persons with disabilities have an opportunity to organize, develop and participate in disability-specific sporting and recreational activities and, to this end, encourage the provision, on an equal basis with others, of appropriate instruction, training and resources; (UN 2006 Article 30.5, pg. 21 - 22)   

A rights-based approach to sport and physical activity is promoted by the Convention, which means not only the promotion of participation but more importantly of ‘QUALITY’ participation (Walker 2007). Cevra (2007) points out that the central aim of this rights based approach is in the empowerment of people with a disability to demand their rightful entitlements and fully participate in society, promoting equality and challenging discrimination.

The Convention received its 20th ratification on the 3rd of April 2008, triggering the entry into force of the Convention and its Optional Protocol on the 12th May 2008 marking a milestone in the effort to promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms of people with a disability (UN 2008c).

History of Sport for Spinal Cord Injury

Throughout the 18th and 19th Centuries sport and physical activity began to be viewed as a tool for the rehabilitation of people with a disability (IPC 2008d). But unquestionably it was Dr. Ludwig Guttmann, seen by some as the Paralympic Games equivalent to Pierre De Coubertin, who was one of the instrumental figures in establishing what has today become the International Paralympic Movement (Bailey 2008). 
“Dr Guttman, you are the De Coubertin of the Paralysed” (Pope John Paul XXIII, cited in Bailey 2008, p.24)
Guttmann founded the National Spinal Injuries Unit at the Stoke Mandeville Hospital in Aylesbury, England at the request of the British Government in 1944 to address the needs of the large numbers of civilians and soldiers injured during World War II (IPC 2008d, DePauw & Gavron 2005, Bailey 2008). Guttman was a strong believer in ‘purposeful, dynamic physical management’ (Bailey 2008, p.17), the role that sport could play in the physical and mental rehabilitation of people with a spinal cord injury. So sport was introduced to the programme at Stoke Mandeville Hospital and became a vital element in the treatment of all patients (Bailey 2008, IPC 2008d). Wheelchair Polo was the first competitive team sport developed at Stoke Mandeville but it was on the 28 July 1948, ‘by chance more than by design’, that the foundation of the first annual sports day, known as the ‘Stoke Mandeville Games’, coincided with the Opening Ceremony of the Olympic Games in London (Bailey 2008, p.18). 

The role of sport in the medical rehabilitation and treatment of people with a spinal cord injury, continued to grow throughout the late 1940’s and early 1950’s (DePauw & Gavron 2005). Many medical and administrative personnel from around the world visited Stoke Mandeville Hospital to observe the work of Guttmann in order to develop and shape procedures back in their home countries (Bailey 2008). It was partly through this cooperation that the first International Stoke Mandeville Games were established in 1952, when a team of Dutch ex-servicemen from the Aardenburg Rehabilitation Centre in the Netherlands travelled to Stoke Mandeville to compete in the Games (Bailey 2008). This was the first step towards Guttmann’s vision for a ‘truly international’ Games that would be the equivalent of the Olympic Games for men and women with a disability (Bailey 2008, IPC 2008d).The International Stoke Mandeville Games continued annually in Aylesbury, with increasing numbers of countries and participants each year but was still only catering for athletes with a spinal cord injury. With this increase in international sports competition for people with a spinal cord injury there grew a need for a common and consistent approach to sports rules and regulations. This was discussed at a ‘Meeting of Experts on Sports for the Disabled’ convened by the World Veterans Federation in Paris, 1957 who agreed that ‘international sporting regulations for ‘able-bodied sport be applied as closely as possible’ (Bailey 2008, p.20),with standardisation of modifications made through regular communication between technical experts.  

Following the 1957 International Stoke Mandeville Games, the first technical meeting elected an appeals tribunal and agreed a central role for the Stoke Mandeville Committee in relation to rules and technical matters of competition (Bailey 2008). It was 1960, in Rome, that saw the next step in the development of international sport competition for people with a disability when, for the first time, the International Stoke Mandeville Games were staged in an ‘Olympic Year in connection with the Olympic Games’ (Guttmann, cited in Bailey 2008, p.19). Four hundred competitors, all with spinal cord injury, from 23 different countries competed in the Olympic Stadium. These games have since become recognised historically as the ‘First Summer Paralympic Games’ (IPC 2008d). 

The growth of the Paralympic Movement continued with a gradual expansion of sport events, countries and other disabilities competing at the annual International Stoke Mandeville Games which were held in Aylesbury three years out of four; and in the Olympic Year held in conjunction with the Olympic Games in the fourth year of the cycle. The Paralympic Games continue to be held, with few exceptions, in the same city and, since 1988 Seoul Summer Games and 1992 Tignes-Albertville Winter Games, at the same venue as the Olympic Games every four years.
Sport should become a driving force for the disabled to seek or restore his (sic) contact with the world around him and thus his recognition as an equal and respected citizen” (Guttman, cited in Council of Europe 1987, p.11)

Participation Rates

There is limited descriptive and comparative data on the participation rates and physical activity patterns of people with a disability, in particular spinal cord injury, but where that data does exist, it shows that people with a disability by and large engage in less physical activity than their able-bodied peers (NDA 2005b, WHO 2008a). Global estimate’s suggest that more than 60% of adults worldwide do not engage in levels of physical activity that will benefit their health and that physical inactivity is reported as being even more prevalent among both women and people with a disability (WHO 2003).

The results of a survey carried out by the NDA (2005a) show that people with a disability in Ireland are less likely to be physically active with twice as many taking no regular exercise in comparison to their able-bodied peers. Sport England, the national sports development agency, in two separate surveys on participation in children and adults with a disability show sports participation rates and frequency of participation are significantly lower than their able-bodied counterparts and this remains true for a wide range of disabilities (Sport England 2001 & 2002).

Factors which Influence Participation in Sport

Participation in sport is influenced by a wide variety of factors. These factors include the perceived benefits of participation in sport, however there are also barriers or constraints, which may hinder participation. These factors and others, influencing participation in sport and physical activity have been widely explored in relation to able-bodied sport (Coalter 1993, Koivula 1999, Sport England 2005, WSF 2007) and more recently within the realms of disability sport.  

Initiation into Sport

“It’s all about discovery. My discovery is that swimming opened the door to everything: first it gave me freedom, then a place in society.” (Beatrice Hess, France cited in IPC 2003, pg.8)
There are a number of studies that examine the socialisation of people with a disability into sport. Williams (1994) explored the issue of disability sport socialisation in relation to identity construction and identified three key factors relation to initiation into disability sport; significant others, socialising situations and personal attributes. If we look at significant others Ruddell & Shinew (2006) suggest that multiple agents play a role in an athletes’ introduction to sport, being evident that a number of key individuals can have an influence on a persons socialisation, often working simultaneously with each individual unaware of the other’s influence.

Theses agents included

  • physiotherapist,
  • occupational therapist,
  • therapeutic recreation therapist,
  • social worker,
  • family particularly parents,
  • coaches, and
  • peers who play sport (Ruddell & Shinew 2006).

Williams & Kolkka (1998) and Wu & Willams (2001) discovered similar introductory agents to disability sport with both studies identifying people with a disability who play the sport as the main initial socialisation agent for both men and women. Unlike Olenik (1998) who found that family were the key agents for the socialisation of women with a disability.

If we look at the contexts in which initial participation in sport take place there is much variation depending on the personal attributes of the individual such as; type of impairment, severity, age of onset and gender. For people with a Spinal Cord Injury, an acquired disability, the rehab setting rated as a key social context for re-introduction to sport.

Motives for Participation and Sustained Involvement 

There are now significantly more studies that are exploring the motives behind the participation of people with a disability in sport. Blinde and McCallister (1999) found that people with a disability when asked, participated in physical activity in order to maintain body functionality, for social interaction and for the psychological benefits of sport such as stress relief and increased self confidence. Additionally Henderson and Bendini (1995) cited pleasure, fun, to feel better, to relax and reduce stress and to improve or maintain fitness as the major reasons why people with a disability chose to be physically active. Wu and Williams (2001) discovered similar reasons. This work was conducted with people with a spinal cord injury, both male and female, who saw fitness, fun, health and competition as the major reasons to participate in sport after injury. Here it was noted that rehabilitation and social aspects also influenced the participation of other participants (Wu & Williams 2001). Both the studies by Blinde and McCallister (1999) and Henderson and Bedini (1995) also outline the importance of choice or perception of choice when it comes to ongoing participation in sport and physical activity. She found that female athletes rated friendship in sport as the major motive for participation whereas male athletes were more driven into competition for the need to achieve and obtain status (Fung 1992).

Constraints to Participation

Research on leisure constraints is well established within the field of leisure studies including a wide array of empirical studies and considerable theoretical developments (Jackson & Scott 1999, Crawford & Stodolska 2008). Crawford and Godbey (1987) suggest three main categories in which to classify constraints to participation in leisure:
  • Structural, which includes facilities, time, money and transportation;
  • Intrapersonal, or more specifically the psychological state of the individual such as stress, anxiety, and perceived self-skill; and
  • Interpersonal which explores the interaction between individuals.

More recently, Crawford and Stodolska (2008) present a unique perspective on the constraints faced by athletes with a disability, which incorporates an extension of these (Crawford, Jackson & Godbey 1991, Kay & Jackson 1991) and other traditional leisure constraints models (Henderson & Bialeschki 1993, Hubbard & Mannell 2001), which provides an understanding of the constraints experienced by people with a disability at a societal level. Crawford and Stodolska’s model show layers of constraints that influence an athletes' ability to participate in disability sport and the way that participation then affects the levels of perceived constraints (Crawford & Stodolska 2008) (Figure 1.1).

[null Figure 1.1 Hierarchical Model of Constraints at Societal Level]

The number of studies that focus on the constraints of people with a disability in sport are very limited. Sherrill and Rainbolt (1988) in a study on elite athletes with cerebral palsy found lack of time, inadequate equipment/facilities, no one to train with, lack of transportation, lack of adequate knowledge among coaches, and lack of a regular coach as the major constraints to ongoing, regular participation. Coyle and McKinney (1990) identified many of these same constraints, although they also found more detailed information on the issue of facilities, which they broke down into constraints related to accessibility, distance and availability. Ferrara, Dattilo & Dattilo (1994) again identified inadequate facilities, inadequate equipment, lack of transportation and lack of coaches as major constraints to sports participation but also recognised that athletes experienced different constraints depending on their chosen sport. Blind athletes most often cited transportation as their major constraint whereas wheelchair athletes tended to have more equipment and/or financial constraints (Ferrara et al 1994). Crawford & Stodolska (2008) study within a developing country context, also identify lack of qualified coaches, limited availability of equipment, inadequate facilities, negative attitudes towards people with a disability and lack of financial resources as the major determinants of sports participation or non-participation. One particular study identifies not only the barriers or constraints to physical activity but also identifies a number of factors that could facilitate participation (Rimmer, Riley, Wang, Rauworth & Jurkowski 2004). They identified 178 barriers in their research, which they grouped under a number of themes including barriers related to the natural environment, equipment, economic issues, information, professional knowledge, perceptions and attitudes, and policies (Rimmer et al 2004). 

In many of the studies these same constraints to sport continue to reappear for both adults and children with a disability. The Sport England ‘Disability Survey 2000 Young People With A Disability & Sport’ (2001), found that, in children with a disability, the most common barriers to participation in physical activity were having no one to go with, unsuitability of local sports facilities, a lack of money, and health considerations. Other constraints included lack of transportation, unwelcoming staff, discrimination, children’s own inhibitions, and clubs do not provide for my disability (Sport England 2001). 

In Ireland transportation and accessibility appear to be the major barrier to sports participation by people with a disability.The NDA Survey (2005a) shows that due to problems with accessibility and transportation people with a disability in Ireland are significantly more limited in their social life, in comparison to their able bodied peers. Almost a quarter of people with a disability have reported having no access to transportation, neither public transport nor a car, compared to just 5% of the able-bodied population. 

The NCTC (2003) Consultation Paper, Building Pathways also examines the gaps in the Irish sports system and considers that there is, too often, insufficient acknowledgement of the barriers that exist to participation in sport and physical activity. The report also acknowledges that the National Governing Bodies of Sport are not proactive enough in providing opportunities for people with a disability and that a lack of knowledge and awareness of disability by mainstream coaches make them reluctant to engage with athletes with a disability. The report also outlines the lack of opportunity in the early stages of long-term athlete development, in particular ‘FUNdamentals’ as a major area of concern within disability sport stressing the need to focus on these early phases of development, including physical literacy, within coaching and coach education (NCTC 2002).

The LTAD model, initially developed by Dr Istvan Balyi, is one of the principle models of sport that addresses sports participation throughout the lifespan. The model focuses on maximising player development to encourage a life long commitment to sports and physical activity. This model has been widely accepted worldwide and is being utilised in Ireland to guide the work of sport organisations in coaching and player / athlete services (NCTC 2002). The Building Pathways Report (2003) recognise that shortcomings in the Irish LTAD model during the early phases mean recruitment and talent development of people with a disability are largely neglected and thus many never reach their optimal performance levels (NCTC 2002). In Canada they also recognised this as an issue but have taken strides to change this through the addition of two extra stages within their LTAD model, called Awareness and First Contact/Recruitment, that considers the supplementary factors that may need to be considered when working with athletes with a disability (Canadian Sports Centres 2008).
‘More often than not, barriers are made out of peoples ignorance towards something different.’ (New Zealand Disability Strategy 2001)