International Journal of

Environmental Research
and Public Health

Review
The Sport Training Process of Para-Athletes: A Systematic Review
Manuel Rodríguez Macías, Francisco Javier Giménez Fuentes-Guerra * and Manuel Tomás Abad Robles

Faculty of Education, Psychology and Sport Sciences, University of Huelva, 21071 Huelva, Spain;
manuvva6@gmail.com (M.R.M.); manuel.abad@dempc.uhu.es (M.T.A.R.)
* Correspondence: jfuentes@dempc.uhu.es

Abstract: The aim of this systematic review was to identify the main factors affecting the training
process of para-athletes, as well as the barriers they encounter. For this purpose, a systematic review
was carried out in accordance with the PRISMA declaration guidelines, in which six databases were
analysed (Web of Science, Scopus, SportDiscus, Pubmed, Eric, and PsycInfo). A total of 19 articles
were selected for analysis after applying the inclusion criteria. The results show that the figures of
the coach and families in the sporting and social contexts, respectively, had a relevant influence on
the training process of para-athletes. Furthermore, in terms of psychological aspects, stress reduction,
the importance of self-esteem, and motivation were highlighted. On the other hand, there are some
barriers hindering the training and performance of athletes, which are related to the lack of financial
support, lack of visibility in the media, and dependence on other people. These considerations can be
of great help to coaches and competent institutions in the field (Paralympic committees, federations,
etc.) in order to improve the training process and performance of para-athletes and to eliminate the
barriers encountered by this group, promoting policies which facilitate access to sports for people
with disabilities.
Citation: Rodríguez Macías, M.;
Giménez Fuentes-Guerra, F.J.; Abad Keywords: parasport; para-athletes; adaptive sports; impairment; disability
Robles, M.T. The Sport Training
Process of Para-Athletes: A
Systematic Review. Int. J. Environ.
Res. Public Health 2022, 19, 7242. 1. Introduction
https://doi.org/10.3390/
In their training process, athletes learn and develop a series of physical, technical,
ijerph19127242
tactical, and psychological skills which are adapted to their biological and psychological
Academic Editors: Felipe J. Aidar, characteristics [1]. Therefore, the training process can be defined as an uninterrupted
Filipe Manuel Clemente and Victor period parallel to the evolutionary development of the athlete, in which there is not only
M. Reis the influence of motor aspects but also factors related to cognitive and affective-social pro-
Received: 13 May 2022
cesses [2]. When analysing the most important factors, Kidman [3] considered that parents
Accepted: 10 June 2022
are very powerful socialising agents, as they can exert a great influence on their children in
Published: 13 June 2022
relation to the sport in which they specialise, as well as their adherence to it. On the other
hand, Martinent and Decret [4] stated that the sports training process and performance
Publisher’s Note: MDPI stays neutral
are conditioned by psychological aspects and physical fitness. According to Mujika [5],
with regard to jurisdictional claims in
psychological aspects are determinant when facing a training session or a competition,
published maps and institutional affil-
while Sosa et al. [6] and Williams and Krane [7] believe that self-confidence, motivation,
iations.
concentration, and the control of stress and anxiety are of vital importance, both when it
comes to achieving the proposed objective and in order to reach maximum performance.
In the case of athletes with disabilities, there is also previous research which indicates
Copyright: © 2022 by the authors.
the existence of numerous factors influencing their training. Thus, Willis et al. [8] observed
Licensee MDPI, Basel, Switzerland. that the social context has a relevant influence on this process, while Williamson et al. [9]
This article is an open access article argued that the most important factor during the training of athletes with a disability
distributed under the terms and is the coach’s knowledge of aspects related to rehabilitation, skill level, awareness, and
conditions of the Creative Commons knowing how to provide the athlete with constant safety. Additionally, Durstine et al. [10]
Attribution (CC BY) license (https:// emphasised that for good sport training of people with disabilities, programmes should
creativecommons.org/licenses/by/ focus on flexibility, balance, accessibility, safety, enjoyment, cardiovascular endurance,
4.0/). agility, and muscular strength. Nevertheless, athletes with a disability often have to

Int. J. Environ. Res. Public Health 2022, 19, 7242. https://doi.org/10.3390/ijerph19127242 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2022, 19, 7242 2 of 19

overcome environmental, structural, social, medical, and economic barriers in order to

train [11], which hinders their training and participation in sports [12]. DePauw and
Gavron [13], Rimmer et al. [14], and Shields et al. [15] also considered that there is a number
of physical, emotional, and psychological barriers influencing the training and participation
of these athletes. Sobiecka et al. [16] found that one of the constraints for sport organisations
not providing good training for para-athletes is the lack of funding and that, in sport clubs,
the training process is not subject to any coordination.
Thus far, numerous studies have provided extensive knowledge on the training and
coaching process of non-disabled people, although it is unclear whether these findings
are transferable to para-athletes, as research in this area is at a nascent stage [17]. The
literature draws attention to the lack of sufficient empirical research on the important
components of training para-athletes at the highest levels of sporting prowess and the
obstacles they encounter [16]. There is, therefore, little understanding of the mechanisms
and processes by which athletes with a disability are trained to participate more or less
effectively in competition-oriented physical activity [8]. In this regard, it should be borne
in mind that both influences and constraints may depend on the type of sport in question,
which could be the focus of future research. Thus, further research is needed on the factors
influencing the sport training of those athletes who aspire to compete at the elite level of a
given sport [18], as well as studies analysing the importance of these factors throughout the
training process. In addition, in order to facilitate the acquisition of an optimal competitive
level [19], it is convenient to highlight the need for adequate planning of these factors, as
well as detection of the barriers affecting the training and participation of athletes with
disabilities in sports.
For this reason, in order to increase knowledge about the factors influencing the
training process of para-athletes, as well as to identify the barriers encountered by these
athletes in this process, a systematic review was carried out. The research questions were
the following: (1) What factors have the greatest influence on the training process of para-
athletes, and (2) what are the barriers encountered throughout this process? Thus, the aim
of this systematic review was to determine the factors influencing the training process of
para-athletes, as well as the barriers they encounter.

2. Materials and Methods

In order to undertake this systematic review, the following method was used: the
Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) statement
and the practical guide for systematic reviews [20–22].

2.1. Eligibility Criteria

The inclusion criteria used for the selection of manuscripts were as follows: (1) full-
text articles, (2) the subjects had to be Paralympic athletes, and (3) manuscripts had to be
written in English, Spanish, or Portuguese. On the other hand, the exclusion criteria were
(1) studies not related to the training process of Paralympic athletes, (2) systematic reviews
or literature reviews, and (3) theses, book chapters, or conference proceedings.
Papers meeting all inclusion criteria were incorporated into the systematic review. In
order to reduce selection bias, each study was reviewed independently by two authors
who established whether or not the manuscripts met the inclusion criteria. In case of
discrepancies, these were resolved by the third researcher.

2.2. Search Strategy

A systematic search was performed in six databases (Web of Science, Scopus, Sport-
Discus, Pubmed, Eric, and PsycInfo) during the month of December 2021. Three blocks
were envisaged to elaborate upon the search phrase: (1) adapted sport OR disability sport
OR Paralympic sports OR Paralympic games; (2) Paralympic OR Paralympic athletes OR
disabled athletes OR disability OR impairment; and (3) social context OR environmental
context OR training process OR training OR psychological aspects OR psychological skills
Int. J. Environ. Res. Public Health 2022, 19, 7242 3 of 19

OR technical aspects OR tactical aspects OR technical-tactical aspects OR physical fitness

OR physical condition. The blocks were combined with the Bolean operator AND. For the
development of the search phrase, the thematic blocks were established beforehand. Subse-
quently, after a preliminary search in the different databases and in different articles on the
topic under study, the terms of the phrase were added in each thematic block together with
their corresponding synonyms. The search phrase was entered in English only. It should
be noted that the search was not limited to a specific date.

2.3. Study Selection and Data Extraction Process

Once the database search was completed, the titles and abstracts of the documents
obtained were analysed in order to select those which were directly related to the subject
matter of the study and to eliminate those which did not meet the inclusion criteria. The
population, intervention, control group, and outcome (PICO) components were considered.
After this screening process, the articles were selected for further data collection. A total
of 19 articles were then selected: 6 from Web of Science, 8 from SportDiscus, and 4 from
PsycInfo. No articles meeting the inclusion criteria were found in the Scopus, Eric, or
Pubmed databases. In addition, one article was selected by reviewing the references of the
articles included in the review.

2.4. Quality Assessment

Quality assessment of the selected manuscripts was undertaken using the Standard
Quality Assessment Criteria for quantitative and qualitative studies [23]. This tool is
based on a systematic scoring system for evaluating the quality of studies and serves to
ensure a minimum of quality in a systematic review [23]. For quantitative studies, 14 items
were scored (“yes” = 2, “partial” = 1, and “no” = 0). Items not applicable to a particular
study were marked “n/a” and were excluded from the calculation of the summation score.
The scores of the qualitative investigations were estimated in a similar way, considering
the scores obtained in 10 items. Inter-observer agreement was calculated using the intra-
class correlation coefficient, resulting in a near perfect coefficient of 885 (p < 0.05) [24].
Two researchers assessed the quality of the articles independently. In case of discrepancies,
these were resolved by the third researcher.

3. Results
3.1. Selection of Studies
A total of 2392 results were found in the initial search, and 346 duplicate articles were
removed using Excel version 2020, leaving 2046. Subsequently, 1936 manuscripts were
excluded after screening for the title and abstract. Ninety-two were also removed as they
were systematic or literature reviews. In addition, one article was selected by reviewing
the references of the included articles. Finally, 19 articles were included in this systematic
review, as they met all inclusion criteria (see Figure 1).

3.2. Quality of the Studies

The scores for research quality were expressed as percentages and are shown in
Tables 1 and 2. The overall scores assigned by Rater 1 for qualitative and quantitative
research ranged between 70% and 90%, and between 75% and 100%, respectively, while
Rater 2’s scores ranged between 70% and 100% for qualitative studies and between 75%
and 100% for quantitative studies. For the inclusion of articles, a cut-off point of 70% was
established for all studies.

3.3. Characteristics of the Studies

The characteristics of the participants, sports, and factors of the studies included in
the systematic review are shown in Tables 3 and 4 below. Furthermore, the most salient
aspects of the training process of Paralympic athletes are shown in Table 5.
 Int. J.J. Environ.
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Health 2022,
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21

Figure 1.1.Flowchart
Figure Flowchartofofthe
thesystematic
systematic review
review process
process according
according to PRISMA
to the the PRISMA protocol
protocol declara-
declarations.
tions.

Table 1. Quality
3.2. Quality assessment
of the Studies of qualitative studies.
The scores for research quality were
Studies expressed
Rater 1 (%) as percentages and are2 (%)
Rater shown in Ta-
bles 1Alexander
and 2. The overall
et al. [17] scores assigned by 90 Rater 1 for qualitative and 90 quantitative re-
search Arnold
rangedetbetween
al. [25] 70% and 90%, and80between 75% and 100%, respectively, 80 while
Rater 2’s and
Eddy scores ranged
Mellalieu between 70% and 100%
[26] 85 for qualitative studies and100 between 75%
and 100% Page
foretquantitative
al. [27] 70
studies. For the inclusion 70 of 70% was
of articles, a cut-off point
Rodrigues
established for et
allal. [28]
studies. 80 70
Vieira et al. [29] 80 70
Table 1. Quality assessment of qualitative studies.
Table 2. Quality assessment
Studies of quantitative studies. Rater 1 (%) Rater 2 (%)
Alexander et al. [17] 90 90
Studies Rater 1 (%) Rater 2 (%)
Arnold et al. [25] 80 80
Baĉanac
Eddy andet al. [30] [26]
Mellalieu 75 85 75 100
Jaarsma
Pageetetal.
al. [31]
[27] 90 70 100 70
Kokun and Shamych
Rodrigues et al. [28][32] .86 80 88 70
Martin et al. [33] 95 100
Vieira et al. [29] 80 70
Marín-Urquiza et al. [34] 100 100
Pereira et al. [35] 86 85
Sánchez-Pay and Sanz-Rivas [36] 90 85
Sobiecka et al. [37] 90 100
Sobiecka et al. [38] 95 100
Sobiecka et al. [16] 95 100
Szájer et al. [39] 95 100
Van Biesen et al. [40] 90 90
Wood et al. [41] 86 85
Int. J. Environ. Res. Public Health 2022, 19, 7242 5 of 19

Table 3. Participant characteristics, sports, and factors of the studies included in the systematic review.

Studies Country Subjects Age (M ± SD) Sports Disability Factors

Sport context
Alexander et al. [17] Canada 8 women NR NR NR
Barriers
Visual Social context
Swimming, paratriathlon, athletics,
Arnold et al. [25] NR 18 men 25.44 ± 6.41 Amputation Sport context
cycling, golf, basketball, and cricket
Cerebral palsy Barriers
24 With disability
12 with disability (10 men) With disability (athletics, archery, table tennis, chess,
Visual
(2 women) (28.58 ± 5.71) and cycling)
Baĉanac et al. [30] NR Hearing Psychological
12 without disability Without disability Without disability
Physical
(10 men) (26.21 ± 6.36) (athletics, table tennis, archery, and
(2 women) cycling)
Eddy and Mellalieu
Great Britain 6 (women) 21.8 ± 8.0 Goalball Visual Psychological
[26]
Visual
Alpine skiing, athletics, archery,
76 Amputation Social context
equestrian, rowing, tennis, table tennis,
Jaarsma et al. [31] The Netherlands (20 men) 30.5 ± 9.7 Spinal cord injury Sport context
7-a-side football, cycling, volleyball, and
(46 women) Cerebral palsy Barriers and facilitators
swimming
Neurological
Kokun and Shamych Hearing impairment
Ukraine 36 men NR NR Psychological
[32] Cerebral palsy
Physical
Martin et al. [33] United States 25 women 25.80 ± 5.24 Wheelchair basketball Spinal cord injury Psychological
Spina Bifida
Belgium, Ireland, Alpine skiing, athletics, pétanque,
United Kingdom, cycling, indoor football, goalball, judo,
84
Marín-Urquiza et al. United States, pentathlon, rowing, sailing, archery, Visual
(69 men) NR Psychological
[34] Australia, Canada, sitting volleyball, swimming, table Physical
(15 women)
Portugal, Spain, and tennis, triathlon, wheelchair basketball,
Argentina wheelchair rugby, and powerlifting
6 wheelchair fencing, powerlifting, Psychological
Page et al. [27] United States (2 men) NR swimming, athletics, and wheelchair NR Social context
(6 women) basketball Physical condition
Int. J. Environ. Res. Public Health 2022, 19, 7242 6 of 19

Table 3. Cont.

Studies Country Subjects Age (M ± SD) Sports Disability Factors

Visual
Pereira et al. [35] Brazil 11 men 22.73 ± 5.00 Swimming Physical Psychological
Intellectual
9
Visual Social context
Rodrigues et al. [28] Portugal (8 men) NR Swimming, boccia
Physical Barriers
(1 woman)
Amputation
Sánchez-Pay and
NR 9 men 38.35 ± 11.28 Wheelchair tennis Spinal cord injury Physical condition
Sanz-Rivas [36]
Osteogenesis
Men
89 32 ± 9.7 Horse riding, cycling, athletics, athletics, Psychological
Physical
Sobiecka et al. [37] Poland (58 men) archery, swimming, fencing, tennis, table Social context
Visual
(31 women) Women tennis, and rowing Sport
32 ± 9.32
Psychological
91
Physical Social context
Sobiecka et al. [38] Poland (61 men) NR NR
Visual Sport context
(30 women)
Barriers
Group 1
Men
470
(32 ± 11.0)
Group 1 (324)
Women Psychological
(254 men) Physical
28 ± 8.20 Social context
Sobiecka et al. [16] Poland (70 women) NR Visual
Group 2 Sport context
Group 2 (146) Physical
Men Barriers
(118 men)
(32 ± 12.10)
(28 women)
Women
(33 ± 12.30)
18 with disability
(9 men) With disability
(9 women) (26.33 ± 10.81) Physical
Szájer et al. [39] Hungary Swimming Psychological
35 without disability Without disability Cerebral palsy
(23 men) (23.26 ± 3.85)
(12 women)
Int. J. Environ. Res. Public Health 2022, 19, 7242 7 of 19

Table 3. Cont.

Studies Country Subjects Age (M ± SD) Sports Disability Factors

With disability
Men
71 with disability 27.00 ± 8.00
(41 men) Women
(30 women) 28.00 ± 8.00
Van Biesen et al. [40] Czech Republic Table tennis Intellectual Technical-tactical
17 without disability Without disability
(12 men) Men
(5 women) 24.00 ± 12.00
Women
20.00 ± 9.00
9
Boccia, athletics, volleyball, goalball,
Vieria et al. [29] Brazil (6 men) NR Physical Barriers and facilitators
swimming, and paracanoeing
(3 women)
8 Psychological
Wood et al. [41] NR (5 men) 40.12 ± 12.99 NR NR Sport context
(6 women) Barriers

Table 4. Methodology, objectives, and main findings of the studies included in the systematic review.

Studies Methodology Instrument Objectives Main Findings

All athletes made significant sporting achievements and recognised the
importance and value of their coaches in helping them reach high
Semi-structured and one-to-one Explore the perceptions and experiences of athletes
Alexander et al. [17] Qualitative standards of success. In addition, participants highlighted that male
interviews [42,43] competing in an individual or coercive sport
coaches inappropriately address their disability and gender issues and
how this influenced their psychological well-being.
A total of 316 organisational stressors were identified, which were
Semi-structured and one-to-one Explore the different organisational stressors faced by summarised into 31 concepts and 4 pre-conceptualised exploratory
Arnold et al. [25] Qualitative
interviews [44,45] athletes with a disability schemes: leadership and staff issues, cultural and team issues, logistical
and environmental issues, and performance and personal issues
Int. J. Environ. Res. Public Health 2022, 19, 7242 8 of 19

Table 4. Cont.

Studies Methodology Instrument Objectives Main Findings

The psychological profile of athletes with disabilities is very similar to the
profile of athletes without them, which shows that sports positively
Prove that participation in sport contributes to the
Self-Esteem Scale (RSES) [46] contribute to their physical strength, making them equally prepared for
psychological improvement of people with
Sport Confidence Scale (SC) [47] the best results in sports as athletes without disabilities. The practice of
disabilities, as well as help them develop positive
Baĉanac et al. [30] Quantitative Athletic Coping Skills Inventory-28 [48] sport has a positive impact not only on self-confidence in sports but also
attitudes towards themselves and their general and
Sport Competitive Anxiety Test on the overall self-esteem of athletes with disabilities. Their anxiety about
sporting competence and become more able to cope
(SCATr) [49] competing is optimised, and their psychological abilities to cope with
with stress
stress are improved, making them no different from their
non-disabled peers.
Structured interview developed by the Research the imagery of experiences of visually Participants reported using imagery for cognitive and motivational
Eddy and Mellalieu [26] Qualitative
study’s authors impaired Paralympic athletes purposes in both training and competition
This study indicated that barriers in sport were mainly environmental,
Questionnaire partially based on the
Understand the barriers and facilitators of sport for while facilitators were generally personal factors. Attitude and subjective
Jaarsma et al. [31] Quantitative questionnaire validated by the Mulier
Paralympic athletes rules were considered to be the most important components of the
Instituut [50]
intention to participate in sport.
The results obtained suggest that the most significant incentive for
Paralympic athletes to engage in sports is the moral satisfaction of
Questionnaire developed by the study
winning a competition. Furthermore, there are other important incentives
Kokun and authors Determine the characteristics and common factors of
Quantitative such as opportunities for personal self-fulfilment, socialising with friends,
Shamych [32] Self-efficacy scale [51] Paralympic athletes’ self-fulfilment
the ability to be a full member of society, gaining experience, meeting new
Self-esteem scales [52]
people who could help later in life, opportunities or prospects for travel
abroad, and the pleasure of training.
Profile of Mood State Questionnaire
(POMS) [53] Determine whether personality and mood differences The results revealed that athletes who were part of the Paralympic team
Martin et al. [33] Quantitative Sixteen-Factor Personality Questionnaire existed between elite Paralympic athletes and elite scored higher on toughness and lower on anxiety. In terms of mood,
(16PF) [54], but the fifth edition was athletes who did not qualify for the team Paralympic athletes scored higher in vigour and lower in depressed mood.
used [55]
Athletic Identity Measurement Scale No differences in self-esteem were found between the withdrawn group
Marín-Urquiza (AIMS) [56] Provide more information on Paralympic sport and the active group. However, within the withdrawn group, athletes
Quantitative
et al. [34] Rosenberg Self-Esteem Scale (RSES) [46] transition and its impact on athletes who withdrew involuntarily had significantly lower self-esteem scores
Perceived Stress Scale (PSS) [57] than those who withdrew voluntarily.
Int. J. Environ. Res. Public Health 2022, 19, 7242 9 of 19

Table 4. Cont.

Studies Methodology Instrument Objectives Main Findings

The results revealed a desire to abandon or at least temporarily escape
from the social and physical conditions associated with disability.
Specifically, participants discussed the desire to gain competence for
Qualitative Sports Orientation Researching the reasons why six elite athletes with
Page et al. [27] Qualitative oneself and with others through participation in sport and the desire to
Questionnaire [58] disabilities play sports
stay active to fight the combined effects of being inactive or being disabled.
Additionally, there was the desire to participate in a social activity with
other people with disabilities.
Sport Motivation Scale [59] Research the associations between the hormonal
No significant differences were found between motivation levels, but
Pereira et al. [35] Quantitative Recovery-Stress Questionnaire for profile and the psycho-biological aspects of
significant differences were found in terms of pressure.
Athletes (RESTQ76-Sport) [60] Paralympic athletes during a competition season
The results showed that, in many cases, Paralympic athletes are unhappy
with the limited media coverage, the stigma, and the supremacy of
Semi-structured individual interviews Identify the characteristics and trends of the media
Rodrigues et al. [28] Qualitative football, and there is an evident desire to occupy a more important space
and methods in [61] approach to the Paralympic Movement
in the sporting arena, which confers greater legitimacy and the possibility
of athletic-competitive development, as well as economic and social gains
The results showed that higher-level players have better fitness levels in
Field tests widely used in the assessment Measure the fitness levels of wheelchair tennis
Sánchez-Pay and all tests, finding significant differences in almost all tests. Players with a
Quantitative of tennis players and wheelchair players players and make comparisons according to ranking
Sanz-Rivas [36] higher functional limitation showed lower values, although no statistically
[62–65] and type of injury
significant differences were found.
The results revealed that the athletes were fully satisfied with the camps
(food, accommodation, and sports equipment) and social relations
Evaluate the preparation process of Polish athletes
Interview for male and female athletes (atmosphere of cooperation between athletes and cooperation between
Sobiecka et al. [37] Quantitative with disabilities for the Beijing 2008 Paralympic
training for the Paralympic Games [66] athletes and coaches of national teams of different disciplines). However,
Summer Games
they require more attention in health (medical care and individual
orthopaedic equipment) and contact with the media.
The analysis showed that relationships between athletes were good at all
Present the conditions during the preparations of times, but accommodations and food were poor. Cooperation with
Adjusted questionnaire for disabled
Sobiecka et al. [38] Quantitative Polish athletes for the Paralympic Summer Games doctors, physiotherapists, and masseurs was satisfactory. Consultations
sports [66]
(2004–2012) with the dietician were sporadic and evaluated as poor. Consultations
with sport psychologists were rare, but satisfactory.
Identify the limitations observed in Polish Particularly outstanding difficulties were related to organisational and
Form for male and female athletes of the
Sobiecka et al. [16] Quantitative Paralympic sports in terms of the environment in financial issues. At the same time, the environment was shown to be a
national team [16]
which athletes train on a daily basis differentiating factor.
Int. J. Environ. Res. Public Health 2022, 19, 7242 10 of 19

Table 4. Cont.

Studies Methodology Instrument Objectives Main Findings

Healthy swimmers scored lower on somatic anxiety and higher on
self-confidence, absence of worry, and self-confidence or motivation for
achievement than Paralympic swimmers. When the tests were repeated
Adaptation of the Competitive State
Reveal possible differences in several psychological separately for men and women, the results remained unchanged for
Anxiety Inventory-2 (CSAI-2) [67] from
profiles between Paralympic swimmers and healthy women, while healthy male athletes only scored significantly higher than
the original [68]
Szájer et al. [39] Quantitative swimmers. In addition, another objective was to male Paralympic swimmers in self-confidence and absence of worry. In
Adaptation of the Athletic Coping Skills
explore possible gender differences and differences addition, medal-winning athletes in the overall sample exhibited less
Inventory-28 (ACSI-28) [69] from the
between successful and less successful swimmers. cognitive and somatic anxiety. Para-swimmers with different levels of
original [48]
disability did not differ from each other in any of the measures. The
findings show that para-swimmers experience significant
psychological disadvantages.
Statistical analysis suggested that there were no gender differences in
Determine the technical competence of table tennis
Van Biesen et al. [40] Quantitative Ten different series of 10 identical strokes terms of proficiency. Table tennis players without a disability scored
players with and without intellectual disabilities
significantly better than those without a disability.
The main facilitators mentioned were family support, socialisation,
economic benefits of sport, incentives from rehabilitation centres and
Explore facilitators and barriers to the practice of health professionals, the possibility of visiting new places, enjoyment of
sports by high-performance Brazilian athletes with sport and competition, better perception of their abilities, development of
Vieria et al. [29] Qualitative Semi-structured interview [70]
disabilities actively involved in national or autonomy, and access to places offering free adapted sports. The most
international competitions frequently cited barriers were physical wear and tear, lack of appreciation
and recognition of athletes as sports professionals, lack of sponsorship,
accessibility difficulties, and the lack of media coverage.
Visual and statistical analyses of the data indicated that reductions in
Shortened General Attitudes and Beliefs irrational beliefs were combined with reductions in systolic blood
Scale (SGABS) [71] Examine the immediate effects of rational emotive pressure, indicative of an adaptive physiological response, improved
State Trait Personality Inventory behavioural therapy on psychological, physiological, athletic performance during competition simulations, and reductions in
Wood et al. [41] Quantitative
(STPI) [72] and performance outcomes with elite goal avoidance. In addition, social validation data showed increased
Achievement goals questionnaire Paralympic athletes self-awareness, emotional control, and greater concentration during
(AGQ) [73] competition as a result of the rational emotive behavioural
therapy intervention.
Int. J. Environ. Res. Public Health 2022, 19, 7242 11 of 19

Table 5. Outstanding aspects in the training process of para-athletes.

Sport Context Social Context Psychological Aspects Technical-Tactical Aspects Physical Condition
Importance of the figure of the coach [17]
Significance of the relationship between
Relationship with coaches [16,17,32,37]
athletes [25,27,31]
Necessary training of coaches [16,31] Relevance of self-esteem [30,31,34,39]
Importance of the family [29,31]
Relevance of sport-specific facilities [25,37,41] Importance of health [31]
Barriers:
Importance of having a medical team [35] Reduction of stress [30,33,35,39] and
By disability [16,31] Relevance of technical-tactical Importance of physical
Importance of competing and winning [31] depression [33]
By gender [17,28] aspects [40] condition [27,35,36]
Barriers: Significance of motivation [26,30,31,35]
Dependence on others [31]
Need to adapt sports facilities and increase the Barriers:
Lack of visibility in the media [28,29]
number of sports facilities [16,31] Excessive stress [41]
Lack of sponsors [16] and lack of
Suitability of a medical team [16,38]
facilities, supervision, and transport [31]
Need for more financial support [16,25,28]
Int. J. Environ. Res. Public Health 2022, 19, 7242 12 of 19

4. Discussion
The aim of this systematic review was to identify the factors influencing the training
process of para-athletes, as well as the barriers they encounter. For this purpose, the review
carried out included only research of optimal quality. In this sense, it should be noted that
all the articles included received a score equal to or greater than the cut-off point (≥70%)
at the beginning of the evaluation process, which may be due to the requirement of the
inclusion and exclusion criteria defined previously. In this way, the tool used to assess
the quality of the documents can help to identify differences between the studies and to
synthesise and interpret the main results of the studies [23].
The main results showed that the factors influencing the training process of Paralympic
athletes referred to the sport context, social context, psychological aspects, technical-tactical
contents, and physical condition. In addition, numerous barriers were found in the training
and development process of these athletes.
The training and performance of Paralympic athletes, in relation to the sport context,
is influenced by several aspects [16], among which the figure of the coach stands out both
for the support they offer to the athletes and the relationship they establish with them, as
well as the qualifications they possess [17,38]. Thus, the coach exerts a decisive influence
on athletes with a disability [74] and is a fundamental and essential part of their sports
career [75]. In this regard, Banack et al. [76] reported that athletes who perceive the support
of the coach are more motivated, which generates greater persistence, enjoyment, and
effort. Vella et al. [77] affirmed that a caring relationship between the athlete and the
coach generates a positive atmosphere, and this positively affects performance, as athletes
consider the figure of the coach as a reference [78].
Sport facilities are an essential element in the sport context, but they can become an
obstacle for athletes with disabilities [16,31]. Ellis et al. [79] and Shirazipour et al. [80]
considered that many facilities do not offer accessible services, in many cases making it
difficult for athletes to move from one location to another. Díaz et al. [81] also reflected on
the role of sports equipment for people with disabilities, and they concluded that sports
equipment for these people is very expensive, and it is generally customised according to
the needs of each person, so they can practically only be used by one athlete.
In terms of the social context, the relationship between Paralympic athletes and their
friendships is unquestionable [32]. Sport is considered a normalising agent because it can
become the ideal vehicle for people with a disability to establish and strengthen social
relationships [82]. In this sense, Imms [83] stated that for these athletes, support from
friends, teammates, or national teammates is a key issue to continue participating in sports.
Family also plays a crucial role in the participation of athletes with a disability [29], which
is consistent with the findings of other studies [84,85]. Robinson et al. [86] considered that
participation in sports for Paralympic athletes requires continuous commitment from both
the athlete and the family.
Regarding the psychological factor, the practice of physical activity and sport is
associated with mental health benefits [87,88]. Tasiemski et al. [89] concluded that people
with a disability who are physically active have higher levels of life satisfaction and, as
a consequence, lower levels of stress. Along these lines, Puce et al. [90] stated that there
is a series of psychological mechanisms triggered by the practice of sport, which can
contribute to a reduction in both stress and anxiety. On the other hand, it should be noted
that psychological aspects are determinant in achieving peak performance [25], although
they are sometimes not considered as important as they deserve to be [91]. The results
also highlighted the relevance of self-esteem [30,31,34,39]. Thus, Marsh et al. [92] stated
that positive self-esteem facilitates the desired achievement, which is to win a medal at
the Paralympic Games. Moreover, the level of self-esteem is similar between Paralympic
athletes and athletes from the general population [93]. Pensgaard et al. [94] pointed out the
high levels of resilience of Paralympic athletes, who are considered resilient people because
they have the ability to overcome mistakes and believe that they can achieve success [95].
Psychological studies on Paralympic sport have mainly focused on psychosocial effects, but
Int. J. Environ. Res. Public Health 2022, 19, 7242 13 of 19

it also has other benefits related to the reduction of depression [96], which is underlined in
the study by Martin et al. [33]. This is relevant as people with disabilities are often prone to
suffering from this type of mental disorder [97]. Furthermore, the results highlight that sport
practice reduces anxiety in athletes with disabilities [30,32,39] as well as stress [30,32,35,39].
Nevertheless, sport can also be the source of these psychological problems, as elite athletes
face numerous stressors such as anxiety, pain, or fear of not achieving success [98]. In this
regard, Wilson et al. [99] conducted a study in which they observed that gender has an
influence, as female athletes were more likely to experience anxiety during preparation
for the Paralympic Games than male athletes [99]. In terms of motivation, Szájer et al. [39]
reported higher scores in Paralympic athletes than in non-disabled athletes. Perhaps, as
De Guast et al. [100] considered, a Paralympic athlete uses his or her disability as a source
of motivation and self-improvement. In addition, Shapiro and Martin [101] stated that
motivation in people with disabilities is strongly associated with the competitive world.
Thus, Paralympic athletes who tend to be highly motivated achieve success at a higher rate
than those who are not [76].
The technical-tactical factor was underlined by Van Biesen et al. [40] in relation to the
training process of Paralympic athletes. In this respect, Marszalek et al. [102] stated that
it is necessary to look for the relationship between performance, enjoyment, health, and
technical-tactical factors. In elite sports, technical-tactical aspects are of great importance,
as the aim is for the athlete to achieve optimal performance, which entails improving
these factors during training, with the aim of achieving success during competition at the
Paralympic Games [103]. Again, the role of the coach is essential [104].
Another important factor in the training of Paralympic athletes is physical condi-
tion [27,35,36]. For Jackson [105], the parameters determining physical condition are
strength, speed, flexibility, balance, agility and cardiorespiratory endurance, and body
composition, which have a decisive influence not only on the physical condition of athletes
with a disability but also on sport performance [106]. However, Paralympic athletes tend to
be very susceptible to early fatigue [10] and have higher metabolic costs [107], so addressing
these aspects in the training and performance of these athletes is crucial.
Gender and disability barriers are also a major factor affecting the training and perfor-
mance of Paralympic athletes [16,17,28,31]. Women often do not have access to sports as
easily as men, especially at the competitive level [108]. Furthermore, women’s participation
in sports has been criticised and rejected [109]. For this reason, women in sports have
had no choice but to try to resist these mechanisms of marginalisation [110]. Nonetheless,
women with disabilities are increasingly present in both recreational physical activity and
elite sports [111]. On the other hand, disability barriers directly influence the usual levels
of physical activity [16] and, as a consequence, the participation levels of people with
disabilities [112]. The literature has shown stereotypes about disabilities and described
how people with disabilities are discredited, devalued, and even humiliated for not con-
forming to, among other things, normal physical activity and sport [113]. For these reasons,
people with disabilities feel excluded or alienated from sporting activities and may also
feel frustrated by being treated differently [114–116], which may explain their low level
of participation [117]. In this regard, Cid [118] stated that throughout history, persons
with disabilities have been subjected to rejection and discrimination, and they are usually
relegated to the background in society. At present, however, progress is evident, and we
can see how these people are integrating into the world of work and, little by little, are
overcoming some of the many barriers that affect them. She concludes by saying that it is
essential to continue this work until all persons with disabilities fully enjoy their rights to
integrity, education, work, non-discrimination, and full integration into society.
Another aspect to highlight is the economic barriers [16,25,28,29], since the lack of
sponsorship in Paralympic sport means that athletes are often responsible for paying most
of the expenses involved in elite sports. The media can also be a barrier in Paralympic
sport [28,29]. In this vein, Marín [119] pointed out that it is now clear that sporting activity,
especially elite sports, has achieved great interest from the economic and commercial point
Int. J. Environ. Res. Public Health 2022, 19, 7242 14 of 19

of view, as well as from the media’s follow-up. This author continues to comment that the
professionalisation of sport has led to the commercialisation of the athlete’s image through
activities such as marketing, merchandising, image rights, or media presence. Businesses
and the media tend to focus on sports that have the greatest impact on television. According
to Rimmer [120], both the media and marketing are barriers in the social context, which
considerably limit the sporting participation of people with disabilities due to the lack of
visibility of these athletes.
The findings of the review indicate that some disabilities have been studied more than
others. In this regard, visual and physical disabilities were highlighted. In addition, there
were differences in the factors and barriers studied according to the type of disability. In
this way, and with regard to visual impairment, the main considerations referred to the
fact that the practice of sport had a great impact on the self-confidence and self-esteem
of athletes, as well as the need to work on the control of pressure and stress. In addition,
the main barriers faced by the visually impaired were environmental and financial as
well as poor media coverage, and their main demands were for greater social recognition,
increased economic benefits, as well as better health care [16,25,26,28,30,31,34,35,37,38]. As
for para-athletes with amputations, it should be noted that the main barriers faced by them
were environmental ones, and personal factors were their main facilitators [25,31,36]. Stud-
ies in para-athletes with cerebral palsy revealed the need to work on some psychological
aspects such as self-confidence, motivation, and anxiety control. In addition, the main
facilitators were the people around them, the desire to win a competition, and the social-
isation provided by the practice of sport [25,32,39]. In people with hearing impairment,
the practice of sport contributed positively to self-confidence, self-esteem, and control of
anxiety, while the main facilitators were related to the people around them, the desire to
win a competition, and socialisation [30,32]. Regarding para-athletes with some physical
disability, the practice of sport was also positive. However, it is recommended to con-
tinue working on controlling the pressure exerted by sports, self-confidence, motivation,
and anxiety. This question is important because psychological care in para-athletes is
not usually common [38]. On the other hand, the main barriers faced by persons with
physical disabilities were environmental and financial, along with poor media coverage
and low recognition as professional athletes. The main facilitators were family, socialisation,
enjoyment of sports, and improved self-perception. However, these athletes demanded
greater social and economic benefits [16,28–30,33–35,37–39]. As for people with spinal cord
or neurological injuries, they considered that the main barriers they encountered were the
environmental ones, while the facilitators had to do with personal factors [31]. With regard
to people with intellectual disabilities, the studies revealed the need to work on the control
of the pressure exerted by the practice of sports on people and sports technique [35,40].
Finally, the study by Sánchez-Pay and Sanz-Rivas [36] showed the need to work on physical
condition in athletes with osteogenesis. In summary, the above considerations should be
taken into account in the training process of para-athletes in order to improve or optimise
the training process.
The systematic review conducted has some limitations. First is the existence of few
studies on the subject analysed. In addition, the search was limited to three languages—
Spanish, English, and Portuguese—and it was limited to full-text articles. In the review
carried out, the factors that influence the training of Paralympic athletes and the barriers
they encounter in general were analysed without specifically taking into account the sport
practiced or the disabilities that the athletes had. Therefore, future research could focus on
analysing the differentiated and comparative training process between female and male
Paralympic athletes as well as analyse the factors that influence and limit this process
according to the sports or disabilities presented by the athletes.
With the aim of answering the questions raised at the beginning of the manuscript, it
must be said that the factors influencing the training process of Paralympic athletes refer
to the sporting, social, psychological, technical-tactical, and physical condition spheres.
Furthermore, regarding the main barriers faced by Paralympic athletes, the need for more
Int. J. Environ. Res. Public Health 2022, 19, 7242 15 of 19

financial and technical support, invisibility in the media, disability-related barriers, and
dependence on other people stand out.

5. Conclusions
In the sports training process of para-athletes, contextual (sporting and social), psy-
chological, technical-tactical, and physical condition factors can be distinguished. Among
the factors related to the sports context, the importance of the figure of the coach, his or
her training, and the relationship maintained with the athletes stand out. Social factors
also play an important role, such as the relationships athletes have with each other and
the support of their families. In terms of psychological factors, it is worth mentioning the
importance of self-esteem and motivation, as well as stress reduction. Factors related to
physical condition, technique, and tactics are also relevant. On the other hand, the training
process of Paralympic athletes is influenced to a large extent by numerous barriers, among
which, on the one hand, the economic aspects can be highlighted, as the material, transport,
and facilities they need for sports are very expensive and, on the other hand, the visibility
in the media, as Paralympic sports always appear in the background, which means that
the successes are not so socially recognised and that the support received by these athletes
is minimal.
In summary, the results obtained in this systematic review can be of great help to
coaches and competent institutions in the field (Paralympic committees, federations, etc.)
in order to improve the training process and the performance of para-athletes, as well as
eliminate the barriers that this group encounters and promote policies which facilitate
access to sport for people with disabilities.

Author Contributions: F.J.G.F.-G. and M.T.A.R. designed and supervised the study; M.R.M. analysed
the data; M.T.A.R. and M.R.M. wrote the manuscript and interpreted the findings; F.J.G.F.-G. reviewed
the paper. All authors have read and agreed to the published version of the manuscript.
Funding: This research was funded by the University of Huelva (EPIT 2019, call for grants to support
the integration of the gender perspective in research; Project title: The training process for athletes in
a situation of double de-equality. The case of Spanish Paralympic Women of the 21st Century).
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.

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