50184 POI36310.1177/0309364612450184Jefferies et al.

Prosthetics and Orthotics International

INTERNATIONAL
SOCIETY FOR PROSTHETICS
AND ORTHOTICS

Review
Prosthetics and Orthotics International

The Paralympic athlete: a systematic 36(3) 278289

The International Society for
Prosthetics and Orthotics 2012
review of the psychosocial literature Reprints and permission:
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DOI: 10.1177/0309364612450184
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Philip Jefferies, Pamela Gallagher and Simon Dunne

Abstract
Background: There is a lack of knowledge of the psychosocial wellbeing and attributes of Paralympic athletes. Such
knowledge may reveal what contributes to exceptional performance.
Objectives: To systematically review the literature on psychosocial wellbeing and attributes of the Paralympic athlete.
Study Design: Systematic literature review.
Methods: Five key databases that index psychosocial literature were searched: CINAHL, ISI Web of Science, MEDLINE,
PsycINFO and SportsDiscus.
Results: Sixteen papers were found that met the inclusion criteria. The studies were characterised by heterogeneity of
design, sample characteristics, outcome assessment and outcomes examined. The emerging thematic areas are 1) partici-
pation, motivations and goals; 2) mental imagery; 3) stress and coping; 4) personality; 5) attitudes towards other disabled-
bodied athlete groups; 6) knowledge and attitudes towards doping; and 7) transitions to retirement.
Conclusions: Relative to the biomechanical aspects of the Paralympian, the psychosocial literature remains limited and dif-
fuse. Nonetheless an understanding of the psychosocial profile of these athletes complements the extant physiological
and technological knowledge in enabling a holistic view of what contributes to the successful Paralympic athlete and may
facilitate the team working to optimize performance and wellbeing in these high-performing individuals.

Clinical relevance
An understanding of the psychological profile of the Paralympic athlete complements the extant physiological and
technological knowledge in enabling a holistic view of what contributes to the successful athlete and may facilitate
optimizing performance and wellbeing.

Keywords
Athlete, disability, Paralympics, psychology, sport
Date received: 27 February 2012; accepted: 8 May 2012

Background
though the International Paralympic Council (IPC) classify
Sport opportunities for disabled-bodied individuals have sig-
10 specific categories of impairment that are eligible for
nificantly increased in recent decades, including increasing
participation: impaired muscle power, impaired passive
opportunities for enhanced training and competition. Research
range of movement, limb deficiency, leg length difference,
on the psychosocial aspects of disability sport participation
short stature, hypertonia, ataxia, athetosis, vision impair-
has a relatively short history and disabled-bodied athletes have
ment, and intellectual impairment.3 With the growing
only begun to receive attention in the last 20 years.1
profile of the Paralympic Games and the wide-ranging
Consequently, even less is known about the psychosocial char-
acteristics of disabled-bodied athletes that perform to an elite Dublin City University, School of Nursing and Human Sciences, Dublin,
standard, such as at the Paralympian level. Ireland
The Paralympic Games due to take place in London
Corresponding author:
2012 will be the largest to date, involving 4,200 athletes Pamela Gallagher, Dublin City University, School of Nursing and Human
from 160 countries competing in 20 different sports.2 The Sciences, Dublin 9, Ireland
competing athletes will have a wide range of disabilities, Email: pamela.gallagher@dcu.ie
Jefferies et al. 279
investment that is made in Paralympic athletes to attend
these competitions, it is becoming increasingly important
to understand how these diverse athletes perform to the best
of their abilities, invoking a holistic account of both biome-
chanical and psychosocial attributes.
Some reviews of disability and sport have been under-
taken in the psychosocial literature,4-7 though none, to our
knowledge, have specifically investigated Paralympic ath-
letes. In a related inquiry, Bragaru et al.4 undertook a review
of amputees and sports. Their review focused exclusively
on limb amputation and participation in sport on a wide
range of outcomes including biomechanics, cardiopulmo-
nary function, psychology, sport participation and sport
injuries. Notwithstanding the acknowledged limitations
inherent in the available papers identified by the authors,
they identified, inter alia, the psychological benefits of
sport for people with an amputation. Bragaru et al.4 also
argued that sport participation appears to be hindered to
some extent by the unavailability of a suitable prosthesis,
poor performance or high cost of the prosthesis, inadequate
facilities or insufficient information. Given these chal-
lenges in day-to-day sport participation, participation at an
elite level becomes all the more difficult.
For many disabled-bodied elite athletes, participation
requires the use of advanced and high specification state-
of-the-art assistive and enabling technology, such as wheel-
chair basketball, ice sledge hockey and lower limb amputees
competing in track and field events, yet the athlete is not
independent from the technology they employ. Previous
research has highlighted the role the person plays in mak-
ing the most of the technology and the impact that technol-
ogy can have on the person.8-10
The current review is not directly interested in the psy-
chological benefits of sport for the person with a physical
disability but rather the psychosocial wellbeing and attrib-
utes of athletes with a disability that perform at a Paralympic
standard. Consequently, the aim of this paper was to sys-
tematically review the literature on the psychosocial attrib-
utes and wellbeing of Paralympians. Within the emerging
papers, the relationship between assistive technologies,
such as prosthetics, wheelchairs, or other ambulating or
enabling devices and the Paralympic athlete will also be
reviewed.
Methods
Search Strategy
Five key databases that index relevant literature were
searched throughout the full date range available: CINAHL
Plus (from 1937 to April 2012), ISI Web of Science (sci-
expanded, SSCI, A&HCI; from 1945 to April 2012),
MEDLINE (via OvidSP; from 1946 to April 2012), PsycInfo
(from 1919 to April 2012), and SportDiscus (from 1800 to
April 2012). A supplementary search was conducted using
the Google Scholar search engine to identify any articles that
may not be indexed in the databases (Figure 1).11
An initial search using only permutations of paralym-
pian and psychological/social keywords proved to be
too narrow in producing results. To capture studies involv-
ing Paralympic athletes that may not be indexed under
these terms, the search was broadened to also include the
terms athlete and disability. Wildcards, truncations and
common misspellings of Paralympian/Paralympic were
also employed to maximize results.
Exact search string criteria included:
CINAHL Plus, MEDLINE, Sport Discus: (para-
lymp* or para-lymp* or paraolymp* or para-olymp*
or (athlet* and disab*)) and (psych* or soc*)
ISI Web of Science: TS=((paralymp* or para-lymp*
or para-olymp* or paraolymp* or (athlet* and
disab*)) and (psych* or soc*))
PsycInfo: (paralymp* or para-lymp* or paraolymp*
or para-olymp* or (athlet* and disab*))
Abstracts for all resulting citations were read by one
reviewer (P Jefferies) and where titles and abstract sug-
gested potential relevance based on the inclusion criteria or
where there was insufficient information to assess the
applicability of the inclusion criteria, full texts of the arti-
cles were requested. The full text of the article was initially
reviewed by one author (P Jefferies). If there were out-
standing issues or questions about relevance, the full text
was reviewed by a second reviewer (P Gallagher).
In addition to the results from the databases, the refer-
ences of all the resulting articles were also searched by one
reviewer (P Jefferies) for any additional papers that met the
inclusion criteria.
Inclusion Criteria
For studies to be included in the review, the inclusion criteria
required that (a) the full text must be in English, (b) it must
consist of a study containing empirical data published in a
peer-review journal, and (c) the group sampled must be elite
disabled-bodied athletes performing at the Paralympian level.
To ensure this, we only included studies where athletes were
explicitly stated to have been competing in, qualified for, or
were retiring from Paralympic sport. Participant groups of all
ages were included, as individuals as young as 12 have com-
peted as Paralympians. Studies were excluded where (a) there
was no clear indication of whether an athlete was a Paralympic
athlete, (b) where the sample combined Paralympic athletes
with, and could not be distinguished from, athletes of other
abilities, including those competing in other international
competitions, and (c) where the article did not incorporate
empirical data (e.g. a review or commentary).
Quality Assessment
Studies selected for inclusion in the review were appraised
through a quality assessment (QA) procedure to evaluate
280 Prosthetics and Orthotics International 36(3)

Search: (Paralympian or disabled athlete) and (psychological or social)

223 results in 223 results in ISI 205 results in 440 results in 1,178 results in
CINAHL Plus Web of Science MEDLINE PsycInfo Sport Discus

2,269 publications

544 duplicates
removed

318 non-peer
reviewed sources
52 items selected based
on title and abstract

37 excluded after full

text review
0 papers added from
references of results

1 paper added from Google

Scholar

16 papers included in the

study

Figure 1. Search strategy.

their risk of bias. The QA evaluation tool was derived by
two reviewers (S Dunne and P Jefferies) by adapting the
QA tool of Minis et al.12 Minis et al. provide a visibly com-
prehensive means of QA, but this was adapted using the
guidelines of van Tulder et al.13 and the National Institute
for Health and Clinical Excellence14 to improve its applica-
bility to the large proportion of cross-sectional quantitative
and qualitative study designs that dominated the review.
Using this procedure, studies were given a score of a maxi-
mum of 12 for quantitative studies, and nine for qualitative
studies; a maximum score indicating the best possible
standard for a study. Each study was evaluated by two of
the review authors (S Dunne and P Jefferies) and in the case
of disagreement, consensus was achieved through discus-
sion of the study. A third author (P Gallagher) was available
if disagreement persisted. The outcome of this assessment
can be found in Table 1.
Results
Study Selection
The literature search returned 2,269 citations from the five
databases (223 in CINAHL Plus, 223 in Web of Science,
205 in MEDLINE, 440 in PsycInfo, and 1,178 in Sport
Discus). In total, 544 duplicate citations and 318 non peer-
reviewed sources were removed, reducing the total to 1,407
articles. A further 1,355 citations were excluded upon
checking the title and abstract of each paper against the
inclusion criteria.
Of the remaining 52 articles, a reading of the full text led
to a further 37 being removed due to not matching the
inclusion criteria, five of which were discarded as they
could not be obtained in English, and one of which where
the full text could not be obtained. No further articles were
found through searching the references of all included cita-
tions. One study meeting the inclusion criteria that was not
identified through the database search was added from
searching Google Scholar. Sixteen papers in total were
included in the review.
Overview of the Literature and
Methodological Quality
The key characteristics of the reviewed papers are dis-
played in Tables 1 and 2 below. The literature exploring the
psychosocial characteristics of elite disabled-bodied ath-
letes that compete as Paralympic athletes is diffuse and
Jefferies et al. 281

Table 1. Overview of the quality of studies involved in the review, according to the adapted version of Minis et al.,12 van Tulder
et al.13 and NICE.14

Criteria quantitative studies

Author(s) 1 2 3 4 5 6 7 8 9 10 11 12 Quality
1 Banack et al. (2011)25 + + + + + + + + + + + N/A 11 (excellent)
2 Bhambhani et al. (2010)46 + + + + + + + N/A 7 (good)
3 Campbell and Jones (2002b)33 + + + + + + N/A 6 (good)
4 Cox and Davis (1992)39 + + + + + + + + N/A 8 (good)
5 Fung (1992)17 + + + + + N/A 5 (low)
6 Henschen et al. (1992)34 + + + + + ? + N/A 6 (good)
7 Martin et al. (2011)15 + + + + + + + N/A 7 (good)
8 Mastro et al. (1996)42 + + + + + + + + + + N/A 10 (excellent)
9 Pensgaard et al. (1999)*16 + + + + + + ? + N/A 7 (good)
10 Shearer et al. (2009)31 + + + N/A + + + + 7 (good)
11 Silva et al. (2012)41 + + + + + ? + N/A 6 (good)
Criteria qualitative studies
Author(s) 1 2 3 4 5 6 7 8 9 Quality
1 Campbell and Jones (2002a)32 + + + + + + + + 8 (excellent)
2 Eddy and Mellalieu (2003)30 + + + + + + + + + 9 (excellent)
3 Garci and Mandich (2005)18 + + + + + + + 7 (good)
4 Omar-Fauzee et al. (2010)19 + + + + + + + + 8 (excellent)
5 Pensgaard, Roberts and Ursin (1999)*16 + + ? + + ? + 5 (good)
6 Wheeler et al. (1999)20 ? + + ? + + + 5 (good)
*This study is used in both parts of the table as it employed both quantitative and qualitative methods. +, positive; , negative; ?, not known/unsure;
N/A, not applicable. A quantitative study was judged to be of excellent quality if the score was between 10-12; good when scores fell between 6-9;
and low if below 6 (maximum score = 12). A qualitative study was judged to be of excellent quality if the score was between 8-9; good when scores
fell between 5-7; and low if below 5 (maximum score = 9).

Objective of the study quantitative

1 Clearly stated objective
2 Participant recruitment strategy clearly documented
3 Main features of population/design described
4 Non-responders described and acceptable
5 Evidence of previous research
6 Power from Cohen52 tables acceptable
7 Identified limitations described and acceptable
8 No evidence of selective reporting of results (e.g. non-significant results described and discussed sufficiently)
9 Statistical measures appropriate
10 Measures relevant and defined adequately
11 Results discussed adequately (e.g. inconsistencies in results explained)
12 Presence of a control group
Objective of the study qualitative
1 Qualitative approach acceptable
2 Study aims clear
3 Analysis appropriate for data collected
4 Role of the researcher described in relation to participants
5 Setting (demographics, location, etc.) described sufficiently
6 Data collection method valid for research question
7 Analyses rigorous in relation to the analytical technique selected
8 Data rich and convincing
9 Results discussed beyond a surface level of analysis

diverse. The studies were characterized by heterogeneity of
design, sample characteristics, outcome assessment and
outcomes examined. Consequently the data cannot be
pooled for analytical purposes. The quality assessment
indicated that 5 studies were of excellent quality, 11 were
of good quality, and one was of low quality (one study
was judged twice due to its inclusion of both quantitative
and qualitative methods). Where quality fell, this was often
due to sample sizes being too low for the statistical tech-
nique employed and judgements about the appropriateness
Table 2. Overview of the main features of the included studies that involved psychosocial investigations of Paralympic athletes.
282

Author(s) Study Stated outcome n = Nature of Sport type* Comparison Assessment tool
design measures disability* Group(s)
1 Banack et al. Cross- Perceived coach autonomy 113 CP, visual Track and Sport Climate Questionnaire (Deci and Ryan, 2006); Perceived
(2011)25 sectional support, perceived impairment, field, Competence Items (Amorose, 2003); Perceived Autonomy
(analytic) competence, perceived amputation, wheelchair Scale (Hollembeak and Amorose, 2005); Perceived Related-
autonomy, perceived related- SCI, les basketball, ness (Hollembeak and Amorose, 2005); Intrinsic motivation
ness, intrinsic motivation autres wheelchair subscales of the Sport Motivation Scale (Pelletier et al., 1995)
rugby
2 Bhambhani Cross- Autonomic dysreflexia 99 SCI Not Boosting Questionnaire (non-validated)
et al. (2010)46 sectional knowledge, incidence and specified
(analytic) attitudes
3 Campbell and Cross- Sources of stress (identified) 10 SCI, amputa- Wheelchair Semi-Structured Interview
Jones (2002a)32 sectional tion, spina basketball
(non-analytic) bifida, polio
4 Campbell and Cross- Sources of stress (rated) 10 SCI, amputa- Wheelchair Likert rating of sources of stress (non-validated).
Jones (2002b)33 sectional tion, spina basketball
(analytic) bifida, polio
5 Cox and Cross- Anxiety control, concentration, 81 Not specified Track and ABA Psychological Skills Inventory for Sports
Davis (1992)39 sectional confidence, mental preparation, field, table (n = 50) (Mahoney et al. 1987)
(analytic) motivation, and emphasis on tennis, weight
team goals lifting, swim-
ming, archery,
air rifle
6 Eddy and Cross- Mental imagery in 6 Visual impair- Goalball Semi-Structured Interview
Mellalieu sectional training and competition ment
(2003)30 (non-analytic)
7 Fung Cross- Participation incentives 30 Tetraplegic Track Japanese Motives for Participation Questionnaire
(1992)17 sectional and paraplegic DBA (Gould et al. 1985)
(analytic) (n = 30), US
DBA (n = 30),
GB DBA (n
= 30)
8 Garci and Cross- Participation motivations 16 SCI, other Wheelchair Semi-Structured Interview
Mandich sectional (not rugby
(2005)18 (non-analytic) specified)
9 Henschen et al. Prospective Mood states, state/trait 24 Not Wheelchair Non-finalists Profile of Mood States (McNair et al. 1971); State-Trait
(1992)34 Cohort anxiety, self-concept and specified basketball (n = 15) Anxiety Inventory (Spielberger et al. 1967); Tennessee Self-
achievement motivation Concept Scale (Fitts, 1965); Achievement Motivation Scale for
Sporting Environments (Rushall and Fox, 1980)

(continued)
Prosthetics and Orthotics International 36(3)
Table 2.(continued)

Author(s) Study Stated outcome n = Nature of Sport type* Comparison Assessment tool
design measures disability* Group(s)
10 Martin et al. Cross- Personality and 25 SCI, serious Wheelchair Non-finalists Sixteen Personality Factor Questionnaire (Cattell et al. 1993);
Jefferies et al.

sectional mood states knee basketball (n = 13) Profile of Mood States (Droppleman et al. 1992)
(analytic) dysfunction,
amputation,
spina bifida
11 Mastro et al. Cross- Hierarchies of preference 138 Amputation, Not Athletes With Impairments Attitude Survey (non-validated new)
(1996)42 sectional towards other DBA groups CP, les specified
(analytic) autres, para/
quadriplegia,
visual
impairment
12 Omar-Fauzee Cross-sec- Participation motivations 10 Not Track, Semi-Structured Interview
et al. (2010)19 tional (non- specified weight-lifting,
analytic) table tennis,
wheelchair
racing, yacht-
ing, bowling
13 Pensgaard et al. Cross- Goal orientation, motivational 99 SCI, Winter ABA Perception of Success Questionnaire (Roberts and Om-
(1999)*16 sectional climate and coping strategies amputation, Games (n = 69) mundsen, 1996; Roberts et al. 1998); Perceived Motivational
(analytic) visual impair- Climate in Sport Questionnaire (Roberts and Ommundsen,
ment, CP 1996), COPE inventory (Carver et al. 1989); Semi-Structured
Interview
14 Shearer et al. Experimental Collective efficacy 10 Paraplegia, Wheelchair Collective Efficacy Inventory (Callow et al., 2004); Vividness of
(2009)31 (within group) other (not basketball Movement Imagery Questionnaire and Adapted Vividness of
specified) Movement Imagery Questionnaire (Isaac et al. 1986); Weekly
Imagery Diaries (Shambrook and Bull, 1996); Social Validation
Questionnaire (Ming and Martin, 1996)
15 Silva et al. Cross- Sleep quality, sleepiness, 27 Not Track and Pittsburgh Sleep Quality Index (Buysse et al., 1989); Epworth
(2012)41 sectional chronotype, and anxiety specified field Sleepiness Scale (Pedroso et al., 1998); Horne and stberg
(analytic) Chronotype Questionnaire (Horne and Ostberg, 1976); State-
Trait Anxiety Inventory (Spielberg et al., 1979)
16 Wheeler et al. Cross- Experiences of initiation, 40 SCI Wheelchair Semi-Structured Interview
(1999)20 sectional competition and retirement (paraplegia), basketball,
(non-analytic) quadriplegia, fencing, skiing,
spina bifida, swimming,
amputation, table tennis,
polio, CP track and field,
water polo

AB = able-bodied (non-athlete); ABA = able-bodied athlete; CP = cerebral palsy; DBA = disabled-bodied athlete; SCI = spinal cord injury.
*Disability is reported as it is stated in the study. Sport type is also reported in this manner.
283
284 Prosthetics and Orthotics International 36(3)
of the analytical technique chosen (e.g. the low sample size
supporting a MANOVA in the case of Martin et al. or expli-
cation of the usage of the phenomenological description
approach employed by Pensgaard et al.16).
Design and Sample Characteristics
The majority of studies were cross sectional (analytic) (n =
9). The remaining studies were cross sectional (non-ana-
lytic) (n = 5), prospective cohort (n = 1) and experimental
(within group) study (n = 1). The majority were of quantita-
tive design (n = 10), though there were some qualitative
investigations (n = 5), and one that combined quantitative
and qualitative methods (n = 1). The studies differed in
sample size, ranging from six to 138 participants (M =
46.69, SD = 43.77). Sport type also varied, but wheelchair
basketball was the most common sport (n = 7). The major-
ity of studies did not employ comparison groups (n = 11),
though one compared to able-bodied athletes, one com-
pared to able-bodied non-athletes, two contrasted finalists
with non-finalists, and one contrasted disabled-bodied ath-
letes from three different countries.
Thematic Areas
A thematic assessment of the literature identified a number
of subject areas into which studies could be grouped. These
consist of 1) participation, motivations and goals; 2) mental
imagery; 3) stress and coping; 4) personality; 5) attitudes
towards other disabled-bodied athlete groups; 6) knowl-
edge and attitudes towards doping; and 7) transitions to
retirement.
Participation, Motivations and Goals
Six studies were found to assess the behaviour prompting
and continuing participation in Paralympic sport. In one
investigation, Fung17 surveyed the motivations to partici-
pate in wheelchair athletes (n = 30) from the USA, Great
Britain and Japan, that were competing in track events at
the Seoul 1988 Paralympic Games. Differences in motiva-
tions were found across countries and genders. For instance,
male athletes were found to compete for status and achieve-
ment motivations (F (1,77) = 4.24, p < 0.05), whereas
female athletes demonstrated a stronger preference for the
social aspect of developing friendships (F (1,77) = 4.08,
p < 0.05). As reported by Fung, athletes from the USA and
Great Britain rated fitness (GB males, M = 2.73, SD = 0.30;
GB females, M = 2.62, SD = 0.41; US males, M = 2.77, SD
= 0.31; US females, M = 2.80, SD = 0.20) as the most
important reason for participation, whereas Japanese ath-
letes cited skill development (Japan males, M = 2.43, SD =
0.72; Japan females, M = 2.40, SD = 0.48) and friendship
(Japan females, M = 2.40, SD = 0.45) as the most impor-
tant. Achievement and fostering friendships were also
strong themes reported by Garci and Mandich18 in their
interviews with Canadian wheelchair basketball athletes
(n = 16). Athletes commonly referred to their teammates
and coaches as a second family, often due to the bonds
formed during intensive training periods (e.g. competition
years). Additionally, the desire to attain the highest possible
achievement in the sport and to represent their country
were reported as important motivating factors, as were feel-
ing challenged, overcoming disability, and the recognition
of the individuals as athletes and the sport itself by others.
Omar-Fauzee et al.19 reported that the Malaysian Paralympic
athletes (n = 10) they interviewed cited reasons of fitness,
friendships and rewards. However, they also reported that
athletes competed to relieve stress, being able to showcase
talents to others, and for reasons of desiring travel and
financial gain. In further qualitative investigations, Wheeler
et al.20 concluded that sport was vital to the retired
Paralympic athletes (n = 40) they interviewed, as it became
a central identity through which athletes defined them-
selves and their competence as an individual. An athletic
identity was valued by these individuals as it gave them a
means of being perceived by others as an athlete rather than
primarily a disabled individual. Some even claimed to feel
able-bodied when engaged in the sport. Additionally,
Wheeler et al. suggested that athletes undertook sport as a
means to cope with their disability and the reactions of oth-
ers, by engaging in the sport to prove their own capability
to themselves, which enabled a means of improving self-
esteem and confidence as skills developed. A further moti-
vation was the acceptance of the family of the athlete and
pride instilled through demonstrating their competence and
consequently their perceived worth as a member of
society.
Other investigations have employed theoretical frame-
works to explore how Paralympic athletes are motivated to
participate and succeed in their sports. Pensgaard et al.
assessed Norwegian athletes competing at the 1994 Norway
Winter Paralympics (n = 30), using Achievement Goal
Theory21 to understand how individuals motivate them-
selves to compete. Achievement Goal Theory posits that
individuals partake in sports to demonstrate ability or com-
petence and that there are two different types of achieve-
ment perspectives, depending on how the individual
construes ability and success.22,23 For example, athletes
who measure competence through mastery in their sport,
such as improving a personal best, are said to be task-orien-
tated individuals. Those who evaluate their performance by
comparison to others are said to be ego-orientated. A high
task goal orientation is said to be beneficial in sport.24
Another conception of Achievement Goal Theory has been
used to assess the type of motivational climate perceived by
individuals. This occurs when situational cues in the exter-
nal environment emphasize a given approach to a task. For
instance, when these cues give the impression of improve-
ment or effort, a mastery-orientated climate is perceived.
This is said to be more adaptive, as there is a recognition
that success and effort co-vary. Alternatively, when ability
Jefferies et al. 285
or social comparison is emphasized, a performance-orien-
tated climate is perceived. Pensgaard et al.16 discovered
that Paralympic athletes did not differ from (n = 69)
Olympic athletes in their goal orientations, with both
groups displaying a similarly higher task than ego-oriented
profile. However, the Paralympians perceived a more mas-
tery-orientated climate in their sports than Olympians cli-
mate (F (1,98) = 12.6, p < 0.01).
Banack et al.25 surveyed Canadian athletes competing in
the 2008 Beijing Paralympic Games (n = 113), using Self-
Determination Theory to assess intrinsic motivation to take
part in their sport. Self-Determination Theory26,27 posits that
intrinsic motivation (the motivation to learn a new skill, to
experience an activity for sensory enjoyment, and to become
accomplished through success) is optimal when their percep-
tions of freedom and control in an activity, as well as their
perceived competence and perceptions of being connected to
others are fulfilled. In support of this, the authors found that
perceptions of autonomy and relatedness to others (i.e. team
members) were predicted by coaches promoting autonomy
(e.g. coaches that give constructive feedback; that promote
task-orientated environments; or that give a rationale for
their actions) (R2 = 0.58; 0.45, respectively). Perception of
competence was found to predict the three forms of intrinsic
motivation (to know, R2 = 0.71; to experience, R2 = 0.57; to
accomplish, R2 = 0.63) and perceived autonomy predicted
the aspects of experiencing and accomplishing (R2 = 0.45;
0.39, respectively).
Mental Imagery
It is known that generating specific imagery in sports is
linked to improvements in performance such as enhanced
confidence and self-efficacy.28,29 Eddy and Mellalieu30
investigated visual mental imagery in goalball athletes with
visual impairments (n = 6) that competed at the 2000
Sydney Paralympic Games. All of the athletes were classi-
fied as having a B1 visual impairment, which is a signifi-
cant impairment to sight. Through a content analysis of
semi-structured interviews, the authors discovered that
visual impairment does not limit the ability to utilize men-
tal imagery, indeed, positive, success-orientated imagery
was predominantly used prior to and during the event, but
was also used in training and for analysis post-competition.
In an imagery intervention study conducted by Shearer et
al.,31 wheelchair basketball athletes preparing for the 2008
Beijing Paralympic Games (n = 10) were invited to partake
in a four week programme where they were requested to
generate images of team performance (aided with video
footage) within their sport that would enhance their confi-
dence about their personal and team performance. Results
indicated mixed support for the intervention. In particular,
the intervention was evaluated through a number of self-
report measures, one of which was the collective efficacy
inventory, and though the authors found an increase in
intervention scores relative to baseline in all three of their
regional participant locales (baseline, M = 35.42, SD =
5.75; M = 41.03, SD = 7.90; M = 40.71, SD = 5.21; inter-
vention, M = 46.63, SD = 1.26; M = 45.34, SD = 1.27; M =
42.96, SD = 1.50), there was an unexpected rise in collec-
tive efficacy scores at time points just prior to the interven-
tion, which the authors state would affect evaluations.
However, individuals reported satisfaction with the imagery
training programme across four questions suggesting the
usefulness of the intervention (M = 6.1, SD = 0.88; M = 5.2,
SD = 1.23; M = 5.0, SD = 1.05; M = 4.7, SD = 1.34).
Stress and Coping
Taking part in the Paralympic Games can be an intensely
stressful experience for athletes, and one which is not only
limited to the competition itself. In an exploratory study of
areas of stress, Campbell and Jones32,33 conducted interviews
with (n = 10) wheelchair basketball athletes, identifying 10
specific sources of potential tension. In particular, the
researchers determined concerns before, during and post-
competition, that pertained to preparation, perceived contri-
butions to team events, ruminations on performance, and
managing psychological pressures. For instance, before the
event, athletes were concerned about having to perform con-
sistently well throughout training in order to be on peak form
for selection and the tournament itself. During the event, ath-
letes had concerns about their ability to concentrate and per-
form under pressure, as well as whether they could deal with
poor refereeing decisions. Post-match, participants reported
that evaluations of their own performance from others were
a source of stress, as was responsibility for the team losing,
or how they worked with the team. There were also negative
aspects of the event itself that would present considerable
tension, such as the mode of travel and the time taken to get
to the Games, social and domestic arrangements such as
being away for an extended period of time, poor coach input,
relationship issues, finance and a lack of disability awareness
in catering for needs. Coping strategies were assessed in the
aforementioned study by Pensgaard et al.,16 who determined
that according to the COPE inventory, when faced with
stressful scenarios, Paralympic athletes were found to use
similar coping strategies to their Olympic counterparts, aside
from one emotion-based strategy. Specifically, Olympic ath-
letes employed more redefinition and growth strategies than
did Paralympic athletes (F (1,97) = 6.72, p < 0.01, ES = 0.0),
meaning Olympians invested more energies in re-interpret-
ing situations to view them in a more positive light and tried
to improve themselves from the experience.
Personality
The exploration of mood states, an early technique in sports
psychology, has been used to assess potential unique prop-
erties of the elite disabled-bodied athlete.15,34,35 It has been
286 Prosthetics and Orthotics International 36(3)
proposed that mood states of athletes will correlate with
performance in a sport.36 This hypothesis was developed
into the Profile of Mood States (POMS), which has deter-
mined a unique profile in high-achieving athletes. This pro-
file is depicted as an iceberg when plotted, as out of the six
subscale concepts of vigour, tension, depression, anger,
fatigue and confusion, vigour appears above population
normal levels in these athletes, whereas the other five are
beneath.36 Two studies were conducted with athletes com-
peting for selection in wheelchair basketball Paralympian
teams. In the first, Henschen et al.34 found that those
selected for the US team competing in the 1988 Seoul
Paralympics (n = 9) had lower scores of tension (F (1,22) =
11.77, p = 0.002) and anger (F (1,22) = 4.11, p = 0.055)
than those not selected for the team (n = 15). In the second
study, Martin et al.15 determined that individuals selected
for the US team competing in the 2004 Athens Paralympics
(n = 12) had higher scores of vigour (F (1,23) = 11.58, p =
0.002, 2 = 0.34), and lower confusion
(F (1,23) = 4.96, p = 0.04, 2 = 0.18) and depression (F (1,
23) = 5.83, p < 0.02, 2 = 0.20) than those not selected for
the team (n = 13). Additionally, those selected for the team
were found to be higher in tough-mindedness (F (1,23) =
5.94, p = 0.02, 2 = 0.21) and less anxious (F (1,23) =
14.91, p = 0.001, 2 = 0.39) according to the 16 Personality
Factor Questionnaire.37,38 Those who were selected for the
team also become less trait anxious (F (1,8) = 9.47, p =
0.015) and less self-critical (F(1,8) = 4.33, p = 0.071) as
competition approached.34
In a different form of personality assessment, Cox and
Davis39 compared the psychological skills of wheelchair
athletes training for the 1988 Seoul Paralympic Games (n =
31) with those of a group of able-bodied athletes training
for a regional competition (n = 50). These skills included
anxiety control, concentration, confidence, mental prepara-
tion, motivation and team emphasis and were tested via the
Psychological Skills Inventory for Sports.40 High scores in
each variable indicated greater desirable qualities. Only the
track and field athletes were assessed, due to their compris-
ing nearly half of the Paralympian group (n = 15), with
results indicating that these athletes had significantly higher
scores in anxiety control (F (1,63) = 10.02, p = 0.002), con-
fidence (F (1,63) = 9.51, p = 0.003), and motivation (F
(1,63) = 18.82, p = 0.000), than their able-bodied counter-
parts. In a further study by Silva et al.,41 sleep quality and
anxiety was assessed in athletes competing in the Beijing
2008 Paralympic Games (n = 27). Those that were found to
report poorer sleep reported higher levels of anxiety (72%)
than those with good quality sleep (28%). Additionally,
those presenting poorer sleep quality and sleepier athletes
(general sleepiness in both active and passive situations)
had lower sleep efficiency (time spent asleep compared to
time spent in bed) (p = 0.0119, p = 0.0241, respectively)
and exhibited greater sleep latency (sleepiness during peri-
ods of wakefulness) (p = 0.0068).
Attitudes towards other Disabled-Bodied
Athlete Groups
The Paralympics have expanded over the decades to involve
more disability groupings. Mastro et al.42 conducted
research with athletes on the US team competing in the
1992 Barcelona Paralympics (n = 138), assessing their per-
ceptions of five disability classifications set by the IPC at
the time of publication (amputation, cerebral palsy, para/
quadriplegia, visual impairment and les autres: other
impairments that do not fit the other categories). The
authors found that out of the five groupings, the least pre-
ferred groups were cerebral palsy and visual impairment.
Amputation (7192% preferred by other groups), followed
by les autres, then paraplegia/quadriplegia were judged to
be the more desirable groups (6874% preferred).
Doping
Cheating via doping is a concern in any competitive sport,
and the Paralympics are not exempt from this. In athletes
with spinal cord injury, a reduced sympathetic cardiac
innervation results in a lower maximum heart rate, leading
to limited cardiac output and oxygen uptake. Increasing
both increases exercise capacity and is known to be related
to enhanced performance.43 One compensatory technique is
inducing autonomic dysreflexia (AD), where a dysreflexive
state is voluntarily induced by individuals applying force to
their bodies, such as by clamping urinary catheters to pro-
duce bladder distension, over-tightening leg straps, or
applying pressure to the scrotum. Athletes inducing this
state have reported significantly faster race performance
times.44 According to the IPC, athletes are prohibited from
competing in a dysreflexive state, whether intentional or
otherwise.45 Bhambhani et al.46 investigated the incidence
and attitudes of AD in Paralympic athletes at the 2008
Beijing Paralympic Games (n = 99). They found that 54%
had heard of AD, whereas 39.4% had not, and that signifi-
cantly more males had knowledge of boosting than females
(p = 0.016). Additionally, 16.7% (all male) had used AD at
least once in their athletic career. Furthermore, 48.9% rated
AD as somewhat dangerous, 21.3% as dangerous and
25.5% as very dangerous.
Retirement
As part of the aforementioned study by Wheeler et al.20
experiences of retirement from Paralympic sport were
examined. Only 10% of the sample was deemed to have
emotional adjustment issues (e.g. altered mood state, appe-
tite loss, sense of purpose, impaired social functioning)
upon retiring from disability sport. However, former ath-
letes did disclose that they were not prepared for retire-
ment, in part, reportedly due to not being given any
information by organizations; a lack of support which
Jefferies et al. 287
athletes stated continued throughout their retirement.
Athletes also found it difficult to contemplate giving up all
the personal and social benefits of the sport, and so part of
being unprepared was also due to avoiding considering the
scenario. Consequently, the heavy investment in their sport-
ing career that came at the expense of their education, fam-
ily, friends and finances, was perpetuated, and would then
become salient upon retirement. When considering the rea-
sons for retiring, some athletes did recognize the sacrifices
being made in other areas of their lives and when combined
with constant fatigue, an awareness of age, damage or pain,
and losing positions to newcomers, seasoned athletes found
retirement an increasingly attractive option.
Discussion
The research exploring the psychosocial characteristics of
Paralympic athletes is a small but steadily growing body
of literature. However, the diversity of the topic areas sug-
gests that additional carefully constructed research is
needed before findings can be assessed analytically. For
instance, it is necessary to further investigate the extent of
the impact that various disabilities and sport types can
have to better understand the potential effects of each
characteristic.47,48
Despite this, a number of areas were highlighted in the
review that contribute to a more holistic account of the
Paralympic athlete. For example, to be selected as a
Paralympian, the need to be able to manage and present
lower anxiety levels recurred in a number of studies.15,34,39 It
can also be recognized that athletes engage in Paralympic
sport for accomplishment and prowess, but the reviewed
studies also describe the close friendships that are developed
as a result of participation, and that demonstrating compe-
tency to others was a strong motive for taking part.17-20
The research also indicates areas for maintaining and
addressing the wellbeing of the Paralympic athlete. For
instance, particular areas of stress and tension have been
identified,32,33 and coaches and organizations might consider
how they might work with athletes in order to address these
difficulties.32,33 Given that their career has been cited as a
central part of an athletes identity,20 the transition to retire-
ment is a period of particular relevance for ongoing attention.
Furthermore, this particular review identified limited
research on doping and prejudice or discrimination in
Paralympic events. Nonetheless ongoing education and
awareness of these issues is warranted to foster greater inclu-
sion and acceptance within and beyond disability sport.42
However, we must restate that these findings must be
taken tentatively, especially where it is inferred that
improvements to particular psychosocial characteristics
may lead to enhanced performance. The majority of the lit-
erature did not involve an experimental measure of perfor-
mance and thus it is only a logical inference that management
of variables such as anxiety and sleep quality or the promo-
tion of particular goal orientations will result in improved
athletic prowess. Further experimental intervention
research with larger sample sizes is required to explore
these areas with confidence.49
An interesting observation is that none of the research
identified made explicit reference to the technology
employed by the athletes in their sports. It is our opinion
that future research might find this a useful area for study,
given the evidence of psychosocial effects of assistive tech-
nology that occur in situations other than sport.9,10,50,51
Furthermore, technology for Paralympic athletes serves a
different purpose; it is not about daily functioning, it is
about enabling excellence and elite performance. Prosthetists,
orthotists and professionals play an important role in the
life of an elite disabled-bodied athlete as assistive technol-
ogy devices are specifically developed, often at high cost.
They are not universally available nor automatically pre-
scribed. Users need to agitate for them. The development of
technology is reliant not only on technical expertise but
also by the enthusiasm and desire for improvement by the
end user. A person who is very clear about what they want
and need the technology to achieve is an important member
of the multidisciplinary team.9 Furthermore, such knowl-
edge of the psychosocial characteristics of Paralympian
athletes (e.g. motivations and goals) complements biome-
chanical or physical characteristics and can inform those
working on the multidisciplinary team to match technology
to the person, to facilitate maximum usage and impact
of the technology and to optimise performance and
wellbeing.
Conclusion
This review summarises the psychosocial investigations con-
ducted with Paralympic athletes and highlights areas such as
participation, motivations and goals, mental imagery, stress
and coping, personality, attitudes towards other disabled-bod-
ied athlete groups, knowledge and attitudes towards doping,
and transitions to retirement. Knowledge of the psychosocial
attributes of Paralympic athletes can enable a greater under-
standing of what constitutes a successful Paralympian and
what may contribute to successful performance and wellbeing.
Such knowledge can also facilitate the multidisciplinary team
working with these athletes.
Funding
This research was supported by an Irish Research Council for
Humanities and Social Sciences Postgraduate Research
Scholarship.
Conflict of interest
The authors declare that there is no conflict of interest.
288 Prosthetics and Orthotics International 36(3)
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