Persons with physical disabilities (PPDs) face challenges with regard to maintaining physical fitness due to inactivity and concomitant medical factors. PPDs trend towards less physical activity than those without physical impairments (Glattke et al., 2022), and have been shown to exhibit a reduced quality of life (QoL) and restricted community integration. Moreover, physical inactivity and a lack of physical fitness can exacerbate functional limitations (Garber, 2019). The American College of Sports Medicine categorizes health-related physical fitness components into a five-component grouping consisting of cardiorespiratory endurance, muscular strength, muscular endurance, body composition, and flexibility (Jeong et al., 2020). In the interest of maximizing these parameters to improve QoL in PPDs, there is an increasing emphasis on sport participation for these individuals. In this regard, “adapted/adaptive sports,” or activities that have been modified to allow access for PPDs, have expanded significantly in popularity in recent years (Grams et al., 2016).

Wheelchair basketball (WB) was created in 1946 as a means of rehabilitation for an injured World War II serviceman in the United States. On September 25, 1946, a group of combat veterans in the United States played the first official WB game. A league-level game was first played at the International Stoke Mandeville Games in 1956. From this origin, WB grew quickly. In response to widespread acceptance of the sport globally, the International Stoke Mandeville Games Federation was established in 1973 as the first WB federation. In 1989, the name was changed to the International Wheelchair Basketball Federation (IWBF). Since 1975, the Federation has staged official world championships held biannually after the summer Paralympic Games (Glattke et al., 2022). WB has been a paralympic sport since the inaugural Paralympic Games in Rome in 1960, and it is now played in over 100 nations (Glattke et al., 2022).

Given fundamental differences in player movement, the types of errors that are made, and the functional classification of individuals on the court, WB game regulations differ from traditional basketball game rules. Despite this, WB is played with in-game rules that are nearly comparable to the International Basketball Federation (FIBA) rules. Games last 40 minutes, and court and ball size, half-court rules, duration of shot clocks, personal foul counts and regulations, height of baskets, and point scoring systems are all congruous with FIBA rules. The key difference between traditional basketball and WB, is the classification system which governs WB.

A variety of durable benefits resulting from participation in adapted sports is reported by a recent study (Molik et al., 2017). In the physical domain, PPDs experience substantial benefits with regard to improved functionality (Grams et al., 2016) and demonstrate greater rates of ventilatory threshold, maximal oxygen uptake, and other markers of aerobic fitness (Molik et al., 2017). One such adapted sport is WB. Athletes with physical restrictions such as those with spinal cord injury, post-poliomyelitis sequelae, amputations, cerebral palsy, and other conditions can participate in WB (Crespo-Ruiz and Del Ama-Espinosa, 2011). Given the rise in popularity of WB in recent years both due to its enjoyability for participants and as a spectator (Fliess Douer et al., 2021; Molik et al., 2017), a literature review is indicated focused on both the health aspects of participation in the sport as well as areas of emphasis for competitive advantage for athletes looking to maximize their performance (Rice et al., 2016). Fig. 1 shows the identification and inclusion flowchart for the analyzed studies. Therefore, the purpose of this study was to review the various risks and benefits of WB and explore some of the research which outlines factors that influence WB player performance and conditioning.

To thrive in sports, athletes must be personally, or intrinsically, motivated to participate and excel at the chosen sport (Mudrak et al., 2018). Adapted sports can bring significant advantages to participants. However, these benefits will not be realized if the athlete is not consistently engaged. Athletes who are motivated by external factors such as monetary gain may lack autonomy and feelings of competence, which ultimately may lead to decreased interest in the sport. Previous research has demonstrated that there is no variation in motivation between low-point and high-point players and determined that players are mostly task-oriented (Fliess Douer et al., 2021). That finding implies that physical limitation in WB athletes does not influence goal perspective. Another study questioned 10 female WB players aged 18 to 32 years about their experiences competing at the highest level (Ashton-Shaeffer et al., 2001) and semistructured interviews revealed two major themes. The first subject dealt with resistance and the use of sport to combat stereotypes of disability, sport, and femininity. The second subject dealt with empowerment as a result of sports experiences. Despite the participants being exceptional high-level athletes, they identified the origins of their interest in the sport as being related to the community aspects of WB.

Other research has compared WB athletes and able-bodied basketball players with regards to sport accomplishment orientation (Skordilis et al., 2002). Findings demonstrate that WB athletes scored better on goal orientation and competitiveness ratings than able-bodied basketball players. This research implies that WB players participate in basketball to achieve personal objectives and compete against their peers more so than their able-bodied counterparts (Skordilis et al., 2002). Despite this finding, the data demonstrated that the game outcome was unimportant to either group. Research has also compared the motivational factors of 57 WB players to those of 70 nondisabled basketball players (Dehghansai et al., 2021). That study assessed task and ego orientation, self-efficacy, and items related to family encouragement and athletic participation. Their findings revealed no change in self-efficacy across the groups. Nonetheless, non-PPD athletes outperformed their WB counterparts in both task and ego orientation. WB athletes, on the other hand, scored higher with regards to familial support. Finally, low-point WB players were shown to have worse self-efficacy than high-point players (Dehghansai et al., 2021). The study investigated the coping abilities and motivation of nondisabled and WB basketball players and found contradictory results (Dehghansai et al., 2021). While female WB players scored higher on intrinsic motivation than male WB players, they rated worse on introjection. However, both able-bodied and disabled athletes performed similarly in terms of coping abilities. Thus, these authors found that the two groups had similar motivation for playing basketball and had similar coping skills and methodologies.

Wheelchair mobility in performing quick-turning, forward, and reverse patterns is paramount to optimal performance in WB (De Freitas et al., 2023). While proper muscular and aerobic training is critical to ensure optimal gameplay, ergonomic factors of the wheelchair can impact mobility significantly and should be carefully tailored to each athlete. Wheelchair type and build should also take impairment level into account (Veeger et al., 2019). The frame, front wheels, backrest, footrest, antitip mechanism, rear axle, and main wheels are the essential components of a WB wheelchair (De Freitas et al., 2023).

The effect of wheelchair mass is a topic of current investigation. Present research indicates that additional mass (5- and 10-kg increments) do not significantly increase physical strain in a study with non-PPD participants on a wheelchair treadmill (Cowan et al., 2009). The study investigated these results and found no effect of added bulk (5 kg) on sprint performance, but did note a drop in performance in the Stop-and-Go test (Sagawa et al., 2010). In contradiction, one study found that increasing the mass of the wheelchair by 9.05 kg reduced mean self-selected velocity (Cowan et al., 2009). Some research has suggested that WB injury profile may be influenced by wheelchair design. Higher-quality, lighter-weight competition wheelchairs with frictionless bearings may boost mechanical efficiency and reduce injury burden. Thus, mass reduction is a goal in most modern-design WB wheelchairs. However, wheelchair cost may become prohibitive. Thus, heavy, earlier-model wheelchairs are commonly utilized in lower-level league play (Tachibana et al., 2019).

Alternative wheelchair and interface configurations can be considered based on WB functional level categorization (De Freitas et al., 2023). Active trunk stability and rotation have been identified as essential performance variables and are critical factors in the current WB categorization scheme (Rice et al., 2022). Lower-category players, therefore, may be unable to adjust for the greater distance between the wheelchair handrail and their shoulder center of rotation when in higher seat positions. Furthermore, players with lower classifications generally have lower power outputs than those with higher classifications, further exacerbating this discrepancy (Gil et al., 2015). In response to these concerns, in a systematic field-based examination of elite WB players, a researcher investigated the influence of seat height, mass, and glove wear on mobility performance (Rietveld et al., 2021). That study determined that (1) lowering the seat height by 7.5% resulted in faster performance on wheelchair mobility performance testing, and (2) adding 7.5% more mass to the wheelchair and the use of gloves did not result in a significant difference in performance. These findings held true regardless of categorization, with both high- and low-classification players responding similarly to the interventions.

Intensive training sessions and high-level tournament play raise the risk of trauma and sports-related injuries. Injury pathophysiology in wheelchair athletes is multifactorial. Overuse injuries account for 23%–52% of all injuries soft tissue injuries, and injuries particularly to the upper extremity are common in wheelchair athletics (Fagher et al.,2020). According to Curtis and Dillon (1985), 72% of wheelchair athletes have suffered at least one injury from their sport activity. WB may be particularly high risk, accounting for 24% of all injuries reported in the study. An epidemiological survey of sport-related injuries in WB reveals 54% of athletes reporting significant discomfort during sport, with upper extremity pain accounting for 79% of the overall incidence (Yengo-Kahn et al., 2021). Another study has described high rates of finger injuries from wheelchair collisions and a high incidence of concussion in WB (Wessels et al., 2012). Given the high rates of injury in the sport, education on injury prevention is encouraged, a thorough warm-up is recommended, and hand protection is imperative. It is important to note that specific injuries may require additional rehabilitative efforts, and coaches, athletes, and trainers alike should be attuned to recognition and treatment of these injuries.

WB induces high cardiovascular demand. Athletes display a HR equivalent to values over the anaerobic threshold for about 68% of playtime and a majority of the game may be spent above the lactate turn-point for many athletes (Croft et al., 2010). While research reports a lower percent time above the anaerobic threshold (28% of the playtime), WB remains a high-intensity exercise (Seron et al., 2019). In absolute terms, the HR mean values for players varied between 148 and 163 beats per min (beats/min) during a game of WB. HR peaks were found to be 174 beats/min when assessing only two-quarters of the game and 190 beats/min when monitoring throughout the game (Croft et al., 2010). Another study evaluated HR before and after games in 20 WB top players (10 with neurological disorders and 10 with musculoskeletal problems) during the International WB Championship in Edmonton, Canada and found that athletes with SCI had smaller increases in HR one hour after beginning gameplay than athletes with musculoskeletal impairments (Heyward et al., 2017). Moreover, although elevated HR may induce temperature increases that can raise the risk of hyperthermia, no incidence of heat-related illness occurred in WB athletes during gameplay analysis. Regardless, WB appears to have significant cardiovascular demands with elevated HR throughout gameplay, necessitating high-intensity training to prepare for the physiological requirements of the game (Seron et al., 2019).

WB has become one of the most popular paralympic sports. A complex set of skills are required for shooting a ball from distance, completing layup shots, transferring the ball between players, doing overhead passes, dribbling, and engaging in other play-related activities (Cavedon et al., 2015). WB match-play is characterized by high-intensity intermittent efforts in which accelerative wheeling sprint capacity from a standstill and over short distances play a significant role in in-game performance. Thus, physical strength and power output are paramount to success in WB (Ferro et al., 2016). Croft et al. (2010) have emphasized training at high intensity for shooting, dynamic movement, and rebounding activities for optimal game-ready performance. That study demonstrated improvements in WB players who practice more half-court games to expeditiously train high-intensity technical skills such as turnovers, rotations, rebounding, and shooting (Mason et al., 2018).

While high-intensity training is critical to success in WB, more technical, skill-based training is also fundamental to in-game development. WB players continuously work to enhance their wheelchair movement skills. WB major maneuver operations are divided into two categories: “push” and “pull.” “Push” refers to gripping the rim and pushing it forward to accelerate the wheel, while “pull” refers to grabbing the rim and halting forward progression of the wheels to decelerate the wheelchair. In other words, the “push” action applies force to the wheel in the forward direction, while the “pull” motion applies force in the opposite (backward) direction (Jansen et al., 2002). Additionally, the pivot turn is one of the most crucial tactics to master in WB, as its use allows for a player to effectively push an opponent away to create distance for a shot or pass maneuver. During match analysis of a WB practice game, a total of 1,005 “push” and 152 “pull” actions, 172 pivots, and 192 turn actions were recorded. In WB, it can be difficult to abruptly shift the travelling direction of the wheel. Thus, some players rely on their dominant hands and make consecutive turns in the same direction. Furthermore, complex movements are necessary to evade or interfere with opponents, so multiple maneuver types are often artfully combined (Jansen et al., 2002).

Research has previously described effective strategies for WB play through match analysis and reported a variety of types of activities during gameplay. Players spent 8.9% of their time actively moving the wheelchair at fast pace, 23.5% gliding, 18.2% wrestling for the ball, 0.6% sprinting with the ball, 0.3% shooting, and the remaining 48.3% remaining motionless or on the bench (Johansson et al., 2015). It was also revealed that during game conditions, the length of concerted efforts varies from less than 20 sec in 47.1% of the instances to more than 60 seconds in 11.8% of the cases (Giancamilli et al., 2022). In summation, match analysis of WB demonstrates substantial work outputs required during gameplay and a wide variety of different movements and skills employed throughout the match.

Sleep has been recognized as a significant factor influencing sports performance across a wide array of athletic endeavors (Fullagar et al., 2015). Interestingly, insomnia has been shown to be common in wheelchair sports athletes, and male WB players are more prone to suffer from insomnia than the overall population. Downregulation of core body temperature is critical for peaceful sleep, and deficits in the autonomic and somatic nervous systems, which govern surface blood flow and perspiration, may impede this process in PPDs. Many players train after daily work activities, and practice sessions are likely to end in the evening. Thus, core body temperature may still be elevated at bedtime (Tsunoda et al., 2017).

Additional explanations for insomnia in wheelchair athletes have been proposed. Individuals who have abnormalities of the spine and/or lower limbs regularly wake to shift posture due to discomfort or to prevent pressure sores. Impaired sleep may have a profound effect on WB players. Intervention research found that young adults’ energy and vigor levels declined with nighttime sleep restriction and were restored after 2 days of adequate sleep (Tsunoda et al., 2017). Extending nighttime sleep duration, while beneficial to athletes’ emotional and physical health, is not without certain potential adverse effects in PPDs. Prolonged sleep may increase tissue damage from pressure ulcers in individuals who have trouble shifting positions while sleeping and who may have impaired protective sensory function. According to another study, short naps had a favorable effect on lowering feelings of fatigue and boosting sprint performance in the setting of partial sleep deprivation (Mutsuzaki et al., 2018). Short sleep periods may also be beneficial for wheelchair athletes while decreasing the risk of pressure ulceration (Tsunoda et al., 2017).

Engaging in regular sporting and exercise activities is critical for mental and physical well-being, regardless of whether an individual is physically disabled or able-bodied. WB is a sport that it offers PPDs a variety of scientifically-proven health advantages, and WB categorization systems allow PPDs with varying levels of disability to engage equitably in the sport. WB is extremely competitive at the highest levels but is also widely played recreationally, allowing athletes of all skill levels to reap some of the previously discussed benefits (social, physical, and psychological). WB enhances cardiovascular fitness, improves blood lipid levels, and supports shoulder and trunk muscle strength and endurance. WB has been shown to increase social relationships, improve mental health, and bolster self-esteem. PPDs associate feelings of empowerment with recreational sports, and WB can have profound effects on the QoL for athletes who may have built their social networks around the sport (Ashton-Shaeffer et al., 2001).

The structure, size, and weight of a wheelchair can all have an impact on an athlete’s performance, and newer generation WB wheelchairs are remarkably technically advanced. WB is associated with a variety of injuries, particularly to the upper extremity. The demands of wheelchair propulsion during sport and day-to-day living and the weight-bearing necessary for transfers and everyday activities places particular strain on the shoulder girdle. WB can also result in wrist, elbow, spine, and leg injuries. Proper warm-up, aerobic conditioning, and utilization of sport-specific equipment can help prevent injuries. As athletes display an HR equivalent to values over the anaerobic threshold for the majority of the playtime, WB commands a high cardiovascular load. As a result, WB necessitates high-intensity training to prepare for the physiological requirements of the game. WB match-play is characterized by high-intensity intermittent exertion, and accelerative wheeling sprint capacity from a standstill and over short distances may be crucial for game performance. Muscle strength and power are thus predictors of success in WB.

In conclusion, WB is a complex, highly-physical sport that is enjoyed by many PPDs throughout the world. A large body of research exists delineating cardiovascular and mental health benefits, injury risk, and performance-enhancing strategies in the sport. Future research and policies aimed at expanding sport participation in PPDs should aim to expand upon this body of work so that future generations can continue to enjoy this engaging and beneficial sport.