Opportunities for Participation: A Mapping Review of Inclusive Physical Activity for Youth With Disabilities : Pediatric Physical Therapy

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RESEARCH REPORTS

Opportunities for Participation: A Mapping Review of Inclusive Physical Activity for Youth With Disabilities

Sawade, Samantha PT, DPT

Author Information
Pediatric Physical Therapy 35(1):p 75-83, January 2023. | DOI: 10.1097/PEP.0000000000000973

Abstract

INTRODUCTION

Approximately 75.2% of all children and adolescents do not meet the daily recommendations of moderate-to-vigorous physical activity for youth.1 Children with intellectual disabilities, in particular, participate in far less daily physical activity than their peers developing typically.2 Further, children with physical disabilities are even less likely than their peers to participate in daily physical activity and spend far more time in sedentary behaviors, regardless of an in-school or out-of-school setting.3,4 This increase in sedentary behavior in youth with disabilities can result in obesity and other health risks.3 Regardless of ability level, physical activity participation tends to decrease with age, as programs become more competitive or selective.5 The benefits youth may gain from these activities go beyond the physical to include improved socialization and development of interpersonal skills6 as well as improved understanding and acceptance of disability with peers developing typically.7

According to the 2018 US Report Card on Physical Activity for Children and Youth, only 17% of children with autism spectrum disorder (ASD), 18% of children with Down syndrome (DS), and 11% of children with cerebral palsy (CP) ages 6 to 17 years meet the minimum daily physical activity recommendations for youth. These values tend to be even lower in girls and for minority ethnic groups within the population of children with disabilities, as well as in the overall youth population.8 More specifically, 28% of children with ASD, 31% of children with DS, and 24% of children with CP participate in organized sports programs as compared with 58% of the general youth population.8

School-based physical activity programs are effective at increasing the quantity of physical activity during time spent in school for youth developing typically. However, there is lack of carryover from school-based programs to increasing recreational physical activity time outside the school setting.9 A recent scoping review assessed physical activity programs for children and youth with physical disabilities outside of school.10 There is no current research collectively evaluating both in- and out-of-school physical activity opportunities for youth with intellectual and/or physical disabilities. Given the known discrepancies in physical activity participation between children with various disabilities and their peers developing typically, the opportunities for inclusive and adapted physical activity available to youth with disabilities are worth evaluating.

Several organizations such as the APTA Academy of Pediatric Physical Therapy and the American Occupational Therapy Association have identified the role of professionals “in providing health promotion interventions to increase fitness; enhance wellness; and prevent illness, disease, or severity of disability for all children”11 as well as “to promote active participation in activities or occupations that are meaningful to them.”12 For many children without disabilities, physical fitness takes the form of structured, group physical activity programs, which may not be accessible to children with disabilities. Coaches, trainers, teachers, and rehabilitation therapists in particular are well positioned to promote adapted physical activity opportunities for children with disabilities through interventions that address physical preparation for an activity (through activity-specific training), and through critical problem-solving and knowledge of appropriate equipment modifications that can facilitate full participation.13 To effectively intervene, address necessary barriers, and promote successful involvement in a child's desired recreational activities, therapists, coaches, and trainers should be familiar with the evidence pertaining to adapted and inclusive physical activity.

The purpose of this review is to map the literature regarding inclusive and adapted physical activity in both in-school and out-of-school settings for children and adolescents with intellectual and/or physical disabilities. Due to the psychosocial benefits of organized physical activity experience, such as improving self-esteem and increasing opportunities for positive social interaction,6 this review includes only group-based inclusive and adapted physical activity programs, rather than individually adapted activities. Due to the varying forms and definitions of both disability and sports, a great deal of heterogeneity is expected in the literature. A mapping review was selected as the ideal means of collecting the breadth of possible research related to the intersection of sports and disability. Mapping reviews are meant to highlight activity related to the study of a topic, such as the locations where literature is being completed and what type of research is being done, without extensively discussing the collective findings of the literature.14 Additional themes included in this review are the outcomes measured, characteristics of participants, and nature of interventions most common in the literature. This review aims to provide an understanding of the current state of the evidence, quality of the literature, and, most importantly, serve to identify the gaps in the current body of research related to inclusive and adapted physical activity.

METHODS

Eligibility Criteria

The eligibility requirements were broad. Inclusion criteria were for original, peer-reviewed articles with (1) any population in which youth ages 3 to 21 years were participants in inclusive or adapted physical activity; (2) individuals with a formally diagnosed physical and/or intellectual disability or the caregivers and providers of individuals with a disability; and (3) inclusive and/or adapted group-based physical activity interventions or opportunities. Studies were excluded if they (1) addressed only nonphysical activity inclusion activities (ie, educational, social, etc); or (2) contained only individual-based adapted programs. Only full-text, English language studies were considered. Given the nature of this review, any quality and type of study was included, regardless of the year of publication.

Search Strategy and Selection of Studies

Figure 1 graphs the process of study selection. A comprehensive English language search was conducted in November 2018, and updated in March 2021 and July 2022, with 5 electronic databases (OVID Medline, PubMed, Web of Science, ERIC, and Embase) in addition to a hand search of the literature. Duplicates were removed and articles were eliminated if they did not meet the selection criteria based on information contained in the title and abstract. A single reviewer examined each of the remaining full-text articles to determine final eligibility for inclusion in the mapping review. A modified version of the Critical Review Form for Quantitative Studies and another for qualitative studies by Law et al15,16 was used to collect pertinent study information such as purpose, design, outcomes, intervention, and results. Studies were excluded if articles were unavailable in full-text, English language format. Search terms for databases are in Supplemental Digital Content 1 (available at: https://links.lww.com/PPT/A421).

F1
Fig.:
Selection of study flow diagram.

Data Collection and Synthesis

Data were collected to map the literature based on several themes: location in which studies were conducted (based on country), type of inclusive or adapted physical activity opportunity, participant demographics, outcome measures used, and study type. Summarized results of each study were also collected and reported qualitatively rather than quantitatively.

Assessment of Risk of Bias and Study Quality

To map the evidence further, and more importantly identify gaps in the current available literature, the Oxford Centre for Evidence-Based Medicine (CEBM) Levels of Evidence17 was used to stratify each study. Quality and risk of bias for included quantitative studies were assessed using the Newcastle-Ottawa Quality Assessment Scale,18,19 the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Reports,20 and the Physiotherapy Evidence Database (PEDro) scale21 (for included cohort, case report, and randomized controlled studies, respectively) and the CEBM Critical Appraisal of Qualitative Studies22 (for included qualitative studies).

RESULTS

A total of 30 articles were included. The data for each study were collected in 2 tables: the Table contains the primary characteristics of each study and the quality of the evidence as per the CEBM Levels of Evidence.17 Supplemental Digital Content 2 (available at: https://links.lww.com/PPT/A422) contains a table summarizing the results of each study to provide insight into common themes in the available literature.

TABLE - Characteristics of Studies
Source Location Intervention Participants/Diagnosis: n (Female); Age, y Outcome Study Type LE
Shields and Synnot23 Australia N/A
Questionnaire
Providers: n = 24 Identifying barriers and facilitators to PA participation for CWD QRCS 4
Wright et al24 Australia N/A
Interviews
CWD: n = 28; 10-17
Providers: n = 6
Identifying barriers and facilitators to PA participation for CWD QRCS 4
Bantjes et al25 South Africa N/A
Interviews
CWD/CP: n = 15; 12-18 Identifying factors to consider when developing sports programs for CWD QRCS 4
Hajjar et al26 United States N/A
Interviews
Providers: n = 9 Identifying benefits and barriers in facilitating adapted PA programs QRCS 4
Shields and Synnot27 Australia N/A
Interviews
CWID/CWPD: n = 23(8)
Parents of CWD: n = 20(18)
Providers: n = 20(11)
Identifying barriers and facilitators to PA participation for CWD QRCS 4
Lundberg et al28 United States N/A
Interviews
CWPD: n = 17; 14-50 Influence of sports participation on qualitative self-perception
Opinion of participants on important outcomes of participation in adaptive sports
QRCS 4
McConkey et al29 United Kingdom N/A
Interviews
CWID
Parents of CWID
Providers
Qualitative information regarding social inclusion in sports for CWID QRCS 4
Lamb et al30 United Kingdom N/A
Interviews
CWD/ASD: n = 5; 12-16 Disposition toward aspects of physical education in schools QRCS 4
Healy et al31 United Kingdom N/A
Interviews
CWD/ASD: n = 12; 9-13 Identification of challenges, peer interactions, and exclusion in inclusive PA QRCS 4
Robinson et al32 Australia N/A
Interviews
Parents of CWD: n = 10; 5-18 Analysis of barriers and facilitators to PA participation in rural areas QRCS 4
Hui-Lun Tsai and Fung33 China N/A
Interviews
Parents of CWID: n = 49(41); 12-50 Analysis of barriers and facilitators to inclusive PE QRCS 4
Dorsch et al34 United States Inclusive outdoor recreation program CWD: n = 5; 24-35
Parents: n = 4
Providers: n = 8
Reflections on previous participation in inclusive PA to identify barriers, facilitators, and benefits for inclusive/adapted PA programs QRCS 4
Kanagasabai et al35 New Zealand N/A
Interviews
CWPD: n = 22; 6-12 Identifying central themes of participation in PA for CWPD QRCS 3b
van Engelen et al36 Netherlands N/A
Interviews
Parents of CWD: n = 17
Providers: n = 40
Identifying barriers, facilitators, and solutions to inclusive playground PA for CWPD QRCS 4
Zitomer and Reid37 Canada Inclusive dance program
1 h, once weekly, 10 wk
CWD/CP: n = 5; 6-9
TDC: n = 9; 6-9
Identifying children's perceptions of dance ability and disability pre- and post-participation in inclusive dance class QPCS 2b
Sterba38 United States Adapted downhill skiing CWD/CP: n = 5(1) Gross Motor Function Measure PCS 3b
Pan et al39 Taiwan Inclusive PE CWD/ASD: n = 25(0); mean 14.26
TDC: n = 75(0); mean 14.08
ActiGraph Accelerometer (physical activity)
Motivation in Physical Education Scale (motivation)
PCS 2b
Peric et al40 Serbia Mixed adapted and inclusive karate classes
1 h, twice weekly, 12 wk
CWID: n = 15(7); 16-19 Adaptive Behavior Scale
Motor Skills 5-point Likert scale
PCS 2b
Groff et al41 United States Any sports participation CWD/CP: n = 73 Athletic Identity Measurement Scale
Influence on Quality of Life Scale
RCS 2b
Fragala-Pinkham et al42 United States Adapted aquatic exercise CWD: n = 16; 6-12 Swimming Classification Scale
Program Evaluation Questionnaire (parent)
Physical Activity Questionnaire
Interview of program directors on sustainability
CHSa 3b
Beckman et al43 Fiji Adapted cricket CWD: n = 54 (19); 12-49 Functional Independence Measure
Pedometers
The Washington Self-Description Questionnaire
Very Short Measure of the Five Cs of Positive Youth Development
Children's Activity Rating Scale
CHS 2b
Pan44 Taiwan Inclusive PE and recess CWD/ASD: n = 24(1); 7-12
TDC: n = 24; 7-12
Accelerometers CS 3b
Turnnidge et al45 Canada Inclusive recreational and elite swimming
10 practices over a course of 6 wk
CWID/CWPD/TDC: n = 24(13); 8-19
Provider: n = 1
Para-Coach Athlete Interaction Coding System
Modified CAICS
Youth Experience Survey for Sport
CS 3b
Lankhorst et al46 Netherlands Any sports participation CWPD: n = 163; 8-19 Health-related cardiovascular fitness: height and body mass, waist and hip circumference, body impedance analysis, arteriography
Health-related physical fitness: grip strength, standing broad jump, 10 × 5-m sprint, muscle power sprint test, cardiopulmonary exercise testing
CS 3b
Neyroud and Newman47 Switzerland Any sports participation Parents of CWD: n = 27 3-level Likert scale on effects of adapted sports in children across 12 domains: sleep, wakefulness, appetite, eating, communication, behavior, attention, mood, well-being, comfort, movement, and activity level CS 4
Oriel et al48 United States Inclusive community aquatics program
8 wk
CWD: n = 10; 5-18
TDC: n = 13; 5-18
PedsQL
Children's Self-Concept Scale
Peer Sociometric Nomination Assessment-Friendship Questionnaire
QES 2b
Papaioannou et al49 Greece Experimental group: summer camp with CWD
Control group: summer camp without CWD
TDC—experimental
n = 197; mean 11.25
TDC—control
n = 190; mean 11.25
Attitudes Toward Integrated Sports Inventory
Children's Attitudes Toward Integrated Physical Education-Revised
QES 2b
Kodish et al50 United States Experimental group:
Inclusive PE
Control group:
Noninclusive PE
CWD/ASD: n = 8(1)
TDC: n = 106
Pedometers
Theory of Planned Behavior Questionnaire
QES 2b
Biricocchi et al51 United States Inclusive tap dance program
1 h, once weekly, 6 wk
CWPD: n = 3(3); 5-6
TDC: n = 1(1); 5-6
Bruininks-Oseretsky Test of Motor Proficiency-2
Pediatric Balance Scale
CR 4
Cook et al52 Canada Experimental group:
Adapted gymnastics
Control group:
Regular daily PA
1 h, twice weekly, 6 wk
CWD/CP: n = 5(4) Height
Weight
Physical Activity Questionnaire for Children
Children's Self Perceptions of Adequacy in and Predilection for PA Scale
Range of motion (goniometry)
Quality Function Measure
RCTa 2b
Abbreviations: ASD, autism spectrum disorder; CAICS, Coach-Athlete Interaction Coding System; CHS, cohort study; CP, cerebral palsy; CR, case report; CS, cross-sectional; CWD, children with disabilities (type not specified); CWID, children with intellectual disabilities; CWPD, children with physical disabilities; LE, level of evidence; N/A, not available; PA, physical activity; PCS, prospective cohort study; PE, physical education; PedsQL, Pediatric Quality of Life Inventory; QES, quasi-experimental study; QPCS, qualitative prospective cohort study; QRCS, qualitative retrospective cohort study; RCS, retrospective cohort study; RCT, randomized controlled trial; TDC, typically developing children.
aPilot study.

Characteristics of the Studies

As illustrated in the Table, the study characteristics were divided into 6 categories: (1) location in which the study was conducted, (2) intervention completed, (3) participant demographics, (4) outcome measures used, (5) type of articles, and (6) level of evidence.17

Location. The included studies originated from a variety of locations. Of the 30 included, 9 were from the United States, 4 from Australia, 3 each from the United Kingdom and Canada, 2 each from Taiwan and the Netherlands, and 1 each from China, Fiji, Greece, New Zealand, Serbia, South Africa, and Switzerland.

Intervention. Multiple interventions were seen in the included studies; however, 15 of the studies had no direct intervention. These studies were based on collected data and interviews with children and adolescents who were affiliated with inclusive or adapted sports programs, or the parents and providers involved with them.

Of the 15 physical activity interventions in the remaining studies, 4 were adapted group-based physical activity opportunities but were not inclusive and 3 were inclusive physical education classes in elementary schools. Eight studies had interventions consisting of inclusive recreational activities such as swimming, winter sports, cricket, karate, gymnastics, dance, or camp-based physical activity.

Participants. There was heterogeneity of study participants. The total number of participants in all studies was 1407, although 1 study did not report the exact number of participants. Of those participants reported, 557 were children/adolescents with some type of perceived disability or formal diagnosis. CP, ASD, and generally labeled “intellectual disability,” “developmental disability,” or “movement or mobility impairment” were the most common diagnoses, although not all studies reported specific diagnoses. One hundred twenty-seven participants were caregivers of children with disabilities, and 108 were providers with inclusive physical activity programs. The largest number of the participants was children developing typically without perceived disabilities, making up 615 of the 1407 participants.

Not all studies reported ages or gender of participants. The youngest ages reported were 2 years, while the oldest included participants up to 50 years of age who were either people with disabilities who began participating in adapted or inclusive physical activity as children, or parents of children with disabilities. Of the studies that reported the gender of participants, the majority of participants were male.

Outcome Measures. The studies used heterogeneous outcome measures. Few quantitative outcomes were repeated in the 30 included studies. Overall, 15 studies were quantitative, using measurable outcome measures to evaluate efficacy or results of programs. The remaining 15 studies were more qualitative, largely reporting on the subjective barriers and facilitators to inclusive and adapted physical activity opportunities.

Type of Article. Of the 30 articles included, 15 were qualitative cohort studies, 14 were retrospective, and 1 was prospective. An additional 6 were quantitative cohort studies, 3 were prospective, 2 retrospective, and 1 pilot study. Three of the studies were quasi-experimental. Of the remaining 6 studies, 4 were cross-sectional, 1 was a case report, and 1 was a randomized controlled pilot study.

Level of Evidence. The level of evidence for each study was evaluated using the CEBM Levels of Evidence system.17 Level 1a includes the highest level of evidence, with level 5 as the lowest. In this review, 9 of the 30 studies were level 2b, 6 were level 3b, and the remaining 15 were level 4.

Risk of Bias and Quality of Evidence

Supplemental Digital Content 3 (available at: https://links.lww.com/PPT/A423) contains the results of the CEBM Critical Appraisal of Qualitative Studies22 for each of the qualitative studies included in this review. A score of 0 indicates a low quality of evidence while a score of 8 indicates a high quality of evidence. Of the 15 included qualitative studies, 3 received a score of 7, 7 received a score of 6, 4 received a score of 5, and 1 received a score of 4. Points were most commonly missed due to bias from use of convenience samples in many studies, and limitation of findings transferrable to other settings.

Quantitative nonrandomized studies were assessed using the Newcastle-Ottawa Quality Assessment Scale.18 Results are in the table in Supplemental Digital Content 4 (available at: https://links.lww.com/PPT/A424). A score of 0 indicates a low-quality assessment and a score of 9 indicates high quality. Of the 13 studies assessed, 2 received a score of 7, 1 received a score of 6, 4 received a score of 5, 2 received a score of 4, 1 received a score of 3, 2 received a score of 1, and 1 received a score of 0. Points were most missed for the category “comparability of cohorts on the basis of the design or analysis” due to limited control of variables.

The single included case report was evaluated for quality using the JBI Critical Appraisal Checklist for Case Reports20 and received a score of 7 of 8, with 8 the score indicating highest possible quality. Results are in Supplemental Digital Content 5 (available at: https://links.lww.com/PPT/A425).

The single randomized controlled study was assessed for risk of bias using the PEDro scale21 and received a score of 4 out of 10, with 10 indicating the lowest risk of bias. Results are in Supplemental Digital Content 6 (available at: https://links.lww.com/PPT/A426).

Summary of Study Results

The heterogeneity of the included studies limits the ability to directly compare results, hence the use of a mapping review for study collection. Supplemental Digital Content 2 (available at: https://links.lww.com/PPT/A422) contains a summary of the results as a reference for each study.

DISCUSSION

There was an encouraging cultural and geographic heterogeneity in the analyzed studies, which originated from 13 countries in 5 continents, suggesting emerging interest and investigation on the topic of inclusive physical activity around the globe. Included interventions were diverse and often reflective of the physical activities valued most in the societies in which the studies were completed. This cultural diversity is important for providers to understand when developing treatment plans, searching for literature, and producing new research, as it provides insight into the participation restrictions and environmental factors facing young people receiving therapeutic intervention. Relevant cultural considerations may include values related to specific activities (such as cricket in Fiji43 or skiing in Colorado26), ease of access in rural versus urban communities,32 monetary expenses related to an activity, and societal attitudes toward disability and inclusion,49 which vary in different cultures. The International Classification of Function, Disability and Health Children and Youth Version (ICF-CY), a conceptual framework used as a clinical reasoning tool for pediatric therapists to catalogue the internal and external factors influencing health in the early decades of life, places special emphasis on the participation and environmental constructs for children and adolescents due to their dynamic influence on development.53,54 A culturally diverse collection of studies, which evaluates these important constructs, can better inform a professional's clinical reasoning and decision-making when developing a person-centered plan of care intended to facilitate participation in meaningful activities.

Despite the heterogeneity of the studies' geography, they yielded several homogeneous results. Four common themes were identified: the recruitment of participants, the characteristics of those participants, the nature of the interventions, and the outcomes measured by studies. Each of these themes has been described in greater detail.

Common Themes

Recruitment and Characteristics of Participants. Many studies had a participant group drawn from convenience samples and included children, families, and providers who were already actively participating or who had previously participated in inclusive or adapted physical activity. It was observed that all the participants were those who required minimal supports—able to walk independently with or without an assistive device and did not require individual attention for medical or behavioral concerns,42 with the exception of the participants in the study by Beckman et al43 and Neyroud and Newman,47 which accounted for approximately 5.75% of the 1407 participants in this review.

The recruitment methods and inclusion or exclusion criteria for many of these studies are understandable and likely the result of the resources available to researchers. There is value in recruiting from current stakeholders who may have better knowledge of what has or has not worked for them in the past. Including only those who are walking with minimal need for supports likely reflects the real-world limitations to participation for many children with disabilities: increased physical disability is a greater barrier to participation.24 However, those who were not reached by the methods of these studies must be considered in future research to better determine the extent of participation barriers. For example, would the reported barriers and facilitators have differed had more participants been interviewed who had never been able to participate in inclusive physical activity? Robinson et al32 in particular surveyed children with disabilities who reside in rural communities and completed focus group interviews with parents to discuss common themes of physical activity participation. In this case, the key barriers were (1) access to appropriate programs, (2) poor physical ability to adequately participate in those activities that were available, and (3) social isolation due to poor peer perception of children with disabilities. These barriers were less extensive than those in studies that occurred in urban settings where opportunity for participation was slightly more available.24,26 Health care providers working in the broad scope of pediatric settings across rural and urban environments may be able to identify populations who are often overlooked in research, or real-world participation, in inclusive physical activity opportunities.

Contrasts were also seen when considering studies based in the school setting, where there were more social barriers rather than physical barriers commonly seen in studies set outside of school.30,31,44 Across all settings, barriers were different for those with more severe disabilities who reported their key limitation was their physical ability to participate, as well as providers' and peers' willingness to accommodate them.24,27,32 This is one area in particular where pediatric therapists may be well equipped to collaborate with coaches and trainers to generate solutions for facilitating participation in physical activity for children with more severe disabilities who require more accommodations than their peers with fewer physical limitations. Pediatric therapists can use their critical thinking and problem-solving skills to educate caregivers, collaborate with coaches, and train participants to optimize participation regardless of the disability severity.13

More comprehensive research of those who have been previously left out of many studies, such as rurally residing people or people with more severe physical or intellectual disability, should be completed to capture additional factors that must be addressed to maximize the efficacy of inclusive physical activity opportunities.

Nature of Interventions. Reviewed studies that included specific activity interventions often assessed activities that were more easily adapted to an individual rather than during a game or team-based experience. For example, Peric et al40 evaluated the effects of an adapted karate program for adolescents with intellectual disabilities. While the program occurred in both an adapted group and an inclusive environment, the nature of the activity allowed participants to focus on their own skills prior to incorporating into the inclusive setting where they were able to receive additional individualized feedback from their peers.40 This appears to be a common approach across the majority of studies and may provide a model for creating participation in programs that have not previously been inclusive. Group-based activities, which lend themselves to individualization based on physical ability, may provide opportunities for shared experiences between children with and without perceived disabilities. Creating more shared experiences may help improve societal perceptions of the ability of children developing atypically to participate in physical activities, as in the study from Papaioannou et al49. regarding the attitudes of children participating in an inclusive summer camp setting.

One study included a team-based intervention (cricket), which varied from individual skill development to group games depending on the number of participants.43 No other studies included in this review evaluated inclusive, team-based physical activity, nor were they found upon searching the literature. Further research into the structure, implementation, and outcomes of team-based (rather than group-based) organized sports may be a valuable next step to expanding inclusive physical activity opportunities.

Outcomes. Several studies identified barriers and facilitators to inclusive physical activity that had been obtained through qualitative methodology.23,24,26,27,32–34 All of those qualitative studies were published within the past 10 years and yielded similar results identifying limitations for inclusive physical activity: inaccessible facilities, lack of adequate transportation, noninclusive providers, and lack of opportunity or choice.23 Facilitators to inclusive physical activity included parental support, accessible facilities, available transportation, and welcoming and inclusive providers.23 While increased physical disability was often a barrier to participation,24 increased availability of adapted equipment was often a facilitator regardless of extent of physical disability.35 The included studies sought information directly from shareholders: parents, providers, and children and adolescents seeking to participate in inclusive physical activity.

The results can provide foresight that can help pediatric therapists and other providers avoid obstacles and maximize facilitators when building a program.13,55 Further, therapists and administrators can use this information to assist patients in gaining access to existing programs by addressing currently known barriers. For example, a therapist may have an opportunity to educate a coach who is apprehensive about coaching a child with a perceived physical or intellectual disability, or they may assist a patient with acquiring necessary adapted equipment.

Only 24% to 31% of children with CP, DS, and ASD participate in organized sports compared with 58% of their peers developing typically.8 Among children ages 10 to 17 years, the prevalence of obesity for children with intellectual disabilities is 28.9% compared with 15.5% for those without an intellectual disability. The extent of fitness disparities between children with CP, DS, and ASD and those without disabilities is difficult to determine due to a scarcity of evidence; however, research shows children with these diagnoses typically present with decreased aerobic and muscular fitness compared with their peers.56–58

The health disparities between these populations demonstrate the vital need to address barriers to participation for children with disabilities. The findings of the included studies lay a valuable foundation for future research aimed at evaluating the efficacy of inclusive physical activity programs and reducing barriers to successful inclusion.

Strengths of the Literature

One of the purposes of this review was to identify the current status of the literature. A notable strength of the evidence is the consistent identification of the barriers and facilitators to inclusive and adapted physical activity. This information is commonly taken directly from key stakeholders who have experience with inclusive physical activity programs. Studies are being produced from a breadth of countries and cultures and are being published by a variety of journals. Many of the studies have been published within the last 15 years, indicating that a current generation of researchers is invested in producing quality inclusive physical activity opportunities for individuals with disabilities.

Gaps in the Literature

A primary aim of this review was to identify key gaps in the literature related to inclusive and adapted group-based physical activity. One of these gaps is the current quality of the evidence. The majority of studies are level 2b or lower according to the CEBM Levels of Evidence system.17 Though the evidence obtained thus far provides good information and an excellent foundation upon which to base additional research, the current evidence is lacking strength and influence.

Several populations have been missed in the research that is currently available. People residing in rural settings and people with more severe behaviors, intellectual disability, or physical disability are often not included in studies and are not captured in the research. There is also a lack of team-based and/or competitive sports represented in the evidence, which would be valuable in influencing the formation of newer, more effective inclusive physical activity programs.

Limitations of the Review

The author recognizes the use of only a single reviewer to search for, select, and evaluate included studies creates an increased potential for bias in the interpretation of the results, and should be noted as a limitation of this review.

Implications for Research

Many studies have repeatedly identified barriers and facilitators to inclusive physical activity. Next steps to understanding the implementation of inclusive physical activity include research to evaluate the efficacy of specific inclusive programs to provide solutions to overcoming barriers and capitalizing on facilitators. Further research should address a variety of settings in both urban and rural locations and should include people with a variety of physical and intellectual disabilities from mild to severe. Further research in these areas can help improve existing programs and develop additional opportunities that reach a broader demographic.

Implications for Clinical Practice

Inclusive physical activity programs are beneficial not only for people with disabilities, but for all participants. Inclusive physical activity opportunities for children with and without disabilities can improve socialization, friendships, and perception of disability for children of all ability levels.6,7 Therapists should use their understanding of the barriers and facilitators to physical activity to maximize participation for all children, both with and without disabilities. For children with disabilities, pediatric therapists have the expertise to intervene in multiple areas such as provider and caregiver education and training, physical conditioning for participants, and equipment modifications that promote inclusion. With greater knowledge of the inclusive physical activity opportunities available to children and their families, pediatric therapists may better fulfill their roles in promoting health and physical fitness for youth of all abilities.

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    Keywords:

    children with disabilities; disability; inclusive physical activity; physical activity participation

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