This document summarizes a presentation on shaping evidence-based social policy for people with disabilities through sport. It finds that while evidence confirms benefits of physical activity for health, evidence for using sport specifically is limited. Studies have narrow ranges of disabilities, interventions, and outcomes, and variable quality. Limitations include underpowered studies, few representing many disabilities, and lack of consistent definitions or theoretical frameworks. Current trends favor lifestyle outcomes and proactive policies. Recommendations include better defining sport as a health intervention, using common frameworks, prioritizing underrepresented groups, and identifying factors affecting sport participation.

1. Shaping evidence-based social policy for the disabled: Making the case for sport to improve health and well-being Liz Adams, MPH, VA Technology Assessment Program, Boston Ted Fay, PhD, SUNY Cortland Presented to: ISDPA Power of Sport Summit June 10-12, 2010

2. Evaluation of sport from an individual & global public health perspective Evidence-based social policy: myths & realities Evidence Current policy trends Recommendations for policy & research Oh, the possibilities!!! Objectives

3. “Public Health is defined as improvement of health through the organized efforts of society—social interventions.” (Gray 1997) Sport is an organized social intervention for health improvement Physical activity through sport is an attainable & essential health behavior A Public Health Perspective

4. Opinion-based Social Policy

5. Evidence-based Social Policy: What it is Policy based on a systematic appraisal of the best available evidence in the context of societal values & available resources (Gray 1997) Evidence = science & experiences

6. Policy makers must have the skills to find & assess the quality & applicability of available evidence Policy shapers must be able to produce & present the evidence on which a decision change should be based To Affect Evidence-based Social Policy

7. Impossible to practice “Cookbook” Restricted to RCTs & meta-analyses Cost-cutting Evidence-based Social Policy: What it isn’t

9. Sport orgs help promote social policies, healthy environments & behavior

10. Effective program development

11. Maximize community participation Evidence-based Social Policy: Why we need it

12. Systematic/critical reviews published from 2000-present in English Databases: Pubmed, EBSCO Rehabilitation and Sports Medicine Source, Cochrane Lib, Embase, Current Contents, Social Science/Science Citation Index, PsychInfo Terms: “sport”, “exercise”, “physical activity”, “physical fitness”, “recreation” & “leisure” All disabilities All outcomes What is the Evidence?

13. Psychological benefits of sport (non-sys review) Empowerment model: performance accomplishments & functional efficiency perceived self-efficacy, self-concept & self-esteem personality disorders, mood states & locus of control activity level & social acceptance Findings: “most psychological constructs expressed within the empowerment model are positively affected by physical activity in disabled people, when applied properly” Multiple study design limitations What is the Evidence? Hutzler 1993

14. Survey of sport disability, age & scientific discipline Most frequent subjects = wheelchair users (58%), adults (90%), males (98%) Most frequent outcomes= physiology (41%), psychology (29%) Findings: Evidence base represented assessment of physiological responses to physical activity in adult males who used wheelchairs What is the Evidence? Hutzler 1999

15. Physical activity & exercise, age ≥ 60 yrs 2 SR + 2 critical reviews: 11- 41 RCTs Findings: Exercise enhances strength, aerobic capacity & function esp. walking, but unclear if exercise prevents or minimizes disability Multiple study design limitations What is the Evidence? Keysor 2003

16. Physical activity in youth w/developmental disability, ages 0-20 3 SR, 1 RCT, 13 uncontrolled studies Findings: Strong evidence for group exercise, treadmill training, therapeutic riding/hippotherapy Lower evidence for adapted skiing, aquatic programs Positive outcomes: enjoyment, satisfaction or physical benefit Study limitations What is the Evidence? Johnson 2009

17. Health promotion activities, age 18-65 80 studies: 32 RCTs, 16 NRCTs, 32 NR uncontrolled Disability groups w/ higher prevalence (20% stroke, 15% MS, 13% intellectual disability (Downs)) Interventions: 26% aerobic, 25% strength, 23% combo Outcomes: 62.5% functional, 42% musculoskel., 27% cardioresp., 26% mental Findings: Overall broad in scope, limited quality & generalizability What is the Evidence? Rimmer 2010

18. Sport & games in ↓ symptoms of PTSD (Lawrence 2010) Policy interventions through sport orgs to promote healthy behavioral changes (Priest 2008) Policy interventions through sport orgs for increasing participation in sport (Priest 2008) Findings: 0 studies met inclusion criteria, largely anecdotal What is the Evidence? Cochrane reviews

19. Evidence represents a narrow range of disabilities, interventions & relevant outcomes in studies of variable quality. Benefits of regular physical activity confirmed in general pop but less clear in disabled pop The effects of sport as a health intervention in the disabled have not been quantified in a meaningful way Conclusions

20. Underpowered Many disabilities under-represented Randomization infrequent or impractical Lack of valid disability outcome measurement tools impairment vs. disability relevance Results not stratified by age, health status, functional level, cause of disability, setting & exposure Poor reporting, no replication Limitations

21. Lacks clear & consistent definition of sport Lacks clear & consistent theoretical framework for eval disabled WHO International Classification of Impairments, Disabilities and Handicaps (ICIDH) 1980 WHO International Classification of Functioning, Disability and Health (ICF) 2001 What and why? Limitations

22. Public Health is paying attention to sport Population is aging Lifestyle and “Real world” outcomes are valued Policy makers want actionable findings Consider consequences of doing something + not doing something Personalized vs. one-size-fits-all Shifting from reactive to proactive Current Public Health Policy Trends

23. It’s difficult to prove cause and effect without good evidence Integrative methodologies Centralized data coordination Define sport as a health intervention Identify & use common theoretical framework Policy and Research Recommendations

24. Prioritize disability groups Innovative recruitment strategies targeted toward non-volunteers Factors affecting participation in sport Effects of assistive technologies Policy and Research Recommendations