Research in Developmental Disabilities 34 (2013) 579–587

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Research in Developmental Disabilities

Psychosocial effects of reverse-integrated basketball activity compared toseparate and no physical activity in young people with physical disability

Yeshayahu Hutzler a,b,*, Anat Chacham-Guber b, Shunit Reiter c

a Zinman College of Physical Education and Sport Science, Israelb Israel Sport Center for the Disabled, Israelc University of Haifa, Faculty of Education, Israel

A R T I C L E I N F O

Article history:

Received 5 August 2012

Received in revised form 13 September 2012

Accepted 14 September 2012

Available online 1 November 2012

Keywords:

Motivation

Functional limitations

Wheelchair sport

Physical disability

Basketball

A B S T R A C T

The purpose of this study was to examine the impact of participation in different sport

modalities on quality of life (QOL) and perceived social competence (PSC) in young people

with physical disability. Ninety participants (33 females and 57 males) were monitored

across four conditions: competitive separate physical activity (COSPA), recreational

separate physical activity (RESPA), reverse-integrated basketball activity (RIBA), and no

physical activity (NOPA). QOL and PSC questionnaires were administered at the beginning

and the end of the study’s duration of six months. ANCOVA corrected for functional

independence and gender revealed significant group effects for pre to post change values

of QOL and PSC, with greater positive change in the RIBA compared to all other groups. In

addition, one-way ANOVA on pre to post change values with LSD post hoc revealed

significant differences. RIBA change values for QOL with 8.77%, and for PSC with 9.98%

change were significantly higher (p < .001) than in all other groups (ranges �0.18 through

1.36% for QOL, and �2.31 through 2.34% for PSC). These outcomes demonstrate a favorable

outcome of the RIBA on participants. Low functional ability did not constrain the effects of

sport participation.

� 2012 Elsevier Ltd. All rights reserved.

1. Introduction

Young people1 with disability often do not have access to social participation opportunities that many other young peopletake for granted. The restrictive and limiting effects of developmental disability on participation in social activities have beenreported for young people with disability in general (e.g., Law et al., 2006; Law, Petrenchik, King, & Hurley, 2007). In studiesconcerning young people with specific disabilities including cerebral palsy (CP: Breslau, 1985; Center & Ward, 1984;Sillanpaa, 1987) and with spina bifida (SB: Lord, Varzos, Behrman, Wicks, & Wicks, 1990; Tew & Lawrence, 1985; Thompson,Kroenenberger, Johnson, & Whiting, 1989; Tin & Teasdale, 1984), participants have demonstrated poorer social activity andadjustment, and fewer inter-personal skills than typically-developing young people.

Leisure time physical activity is an area where the social participation of young people with a disability is particularly lowcompared to peers without a disability (Longmuir & Bar-Or, 2000; Rimmer, 2001). The low participation rate is linked toperceived barriers as well as to reduced opportunities for sport activity in a group, which, has been reported to facilitate

* Corresponding author at: Zinman College of Physical Education and Sport Sciences, Wingate Institute, 42902, Israel.

E-mail address: shayke@wincol.ac.il (Y. Hutzler).1 Due to the variable terminology referring to age spans across childhood, youth, and adolescence, in this study we will use the term young people,

accepted by the World Health Organization (WHO) and related agencies, covering the terms youth and adolescence, and referring to age spans starting at 10

with a range of up to 24 years (WHO, 1989).

0891-4222/$ – see front matter � 2012 Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.ridd.2012.09.010

Y. Hutzler et al. / Research in Developmental Disabilities 34 (2013) 579–587580

young people developing a sense of belonging, accomplishment, and popularity, and in achieving cooperation skills (Koltet al., 1999). Therefore, participation in physical activity and sports has been strongly encouraged in young people withdisabilities for developing their psychosocial skills, performance, and competence (Craven, Blauwert, & Farkas, 2006, chap. 3;Hellison, 2003; Sherrill, 2004).

Introducing and promoting the participation of persons with disabilities in sport activities are possible within servicedelivery modalities ranging from totally separate to completely integrated environments (Block, 2004; Sherrill, 2004).Having a separate sport environment for participants with disability is typically motivated by safety issues, task specificity,and supervisor’s attention, while integrated sport environments are expected to enhance social participation and interactionaspects of the sport activity ((Hutzler & Sherrill, 2007; Sherrill, 2004). Integrated physical activity environments have beenstudied, with lower rates of academic learning time and social interaction with peers being reported during the physicalactivity of young people with disability, when compared to typically-developing children (Block & Obrusnikova, 2007).Furthermore, in-depth interviews with participants in such environments have revealed ambiguous findings, somesuggesting empowering, but others restricting and disempowering psychosocial outcomes (Goodwin & Watkinson, 2000;Hutzler, Fliess, Chacham, & Van den Auweele, 2002).

Reverse integration (RI) is a unique modality of an integrated environment, where persons with disability are the majorityand able-bodied participants the minority (Schoger, 2006). RI may increase the base of recruitment for recreational activities(Schlein, Green, & Stone, 1999) and establish an environment that is both cooperative and competitive, facilitating thedevelopment of positive self-identity, which is crucial for lifelong participation (Brasile, 1992). Brasile (1992) hasrecommended including an RI environment in wheelchair basketball, which is one of the most popular sport and recreationalactivities for adults and young people with disability (IWBF, 2010). However, past research with this modality has focusedonly on the experiences and attitudes of the non-disabled participants (Schoger, 2006; Lundberg, Zabriskie, Smith, & Barney,2008).

The purpose of this study is to examine the contribution of an RI framework in wheelchair basketball compared to othertypes of participation in sport activity or no sport activity, to selected psychosocial attributes, namely quality of life (QOL)and the perception of social competence (SC) in young people with disability. QOL is conceived as a multifaceted concept,and is mostly a matter of subjective judgment (Taylor & Bogdan, 1996). It is typically determined through the congruencybetween subjective expectations and objective social life circumstances (Reiter, 1999). An important aspect of QOL is SC,generally described as effective functioning within social contexts (Cavell, 1990), or as the ability to achieve personal goals insocial interaction while simultaneously maintaining positive relationships with others (US Department of Justice, 2010).

2. Methods

A prospective cohort study was performed, monitoring QOL and SC in a sample of young people with developmentaldisabilities over a period of six months. Cohort studies have been proposed as an appropriate procedure for studying rareexposures, where randomization is impossible due to practical or ethical reasons (Euser, Zoccali, Jager, & Dekker, 2009). Thecohort groups were classified based on the major sport environment in which they were involved.

2.1. Participants

A convenience sample of 100 young people (34 females and 66 males) with physical disability enrolled in this study. Tenparticipants dropped out due to transport problems and difficulties in combining the school load with physical activitytraining. Therefore, the final sample included 90 (33 females and 57 males) participants. About two thirds (64.5%) of theparticipants attended school, with 28 (31.11%) in special education and 30 (33.33%) in regular education. Twelve participants(13.33%) worked at a sheltered environment and 20 (22.22%) worked in the open market or studied in a higher educationenvironment. All participants but one had a congenital disability.

Because it is not permitted to receive participant lists from schools and/or the social security data bases, participants wererecruited through two modalities: (a) letters sent to parents of students in the schools and education districts that hadauthorized the study and (b) letters sent to the homes of individuals based on lists available in the only two sport centers foryoung people with disability in Israel. The inclusion criteria were: (a) age 12–25 years, (b) self-locomotion with or withoutassistive devices, and (c) capable of answering questions and complying with questionnaire instructions. Individuals whohad undergone surgery or other major medical interventions during the six months prior to the study were excluded fromthe cohorts.

2.2. Instrumentation

2.2.1. Personal questionnaire

This questionnaire retrieved information regarding the participant’s age, gender, disability, use of mobility aids, andactual participation in physical activity. Details about participation in physical activity were assessed by means of open-ended questions relating to leisure-time physical activity, based on the questions used by Longmuir and Bar-Or (1994). Thefive items addressed in the questions were: whether the participant was taking part in leisure-time physical activity; thetype, duration, and intensity of the activity; and the activity’s organizational setting (e.g., individual, group, etc.).

Y. Hutzler et al. / Research in Developmental Disabilities 34 (2013) 579–587 581

2.2.2. Functional independence measure (FIM)

To enable the comparison of different disabilities included in each cohort, the Uniform Data System for MedicalRehabilitation Functional Independence Measure (FIM) was used. This is a valid measure widely used internationally forscreening and follow-up purposes during rehabilitation (Deutsch, Braun, & Granger, 1996; Hamilton, Granger, Sherwin,Zielezny, & Tashman, 1987; Ottenbacher, Hsu, Granger, & Fiedler, 1996; Stineman et al., 1996). It includes 18 items scored bypractitioners on a 7-point scale (1 = most dependent; 7 = most independent) related to six categories: (a) Self-help (6 items),(b) Bowel control (2 items), (c) Transfers (3 items), (d) Mobility (2 items), (e) Communication (2 items), and (f) Socialcognition (3 items). Scores of lower than six points indicates that this individual required some kind of attendant assistancefor performing this item. Score range is 18–126 points. Individuals demonstrating higher levels of independence receivehigher scores. In this study only categories (a) through (d), which are relevant to physical activity, were used (13 items intotal), allowing a score range of 13–91. Cronbach’s reliability value compiled for the 13 items in the 100 participants enteringthe study was a = .94.

2.2.3. Perceived Social Competence Scale (PSC)

Due to the lack of appropriate instruments available in the Hebrew language, this scale was specifically developed for thepurpose of this study to be administered in young people with disability in Israel. The development of this instrumentfollowed the guidelines outlined by DeVellis (1991) for scale development, and was conducted in the following steps: (a)considering content by means of literature analysis, (b) creating an item pool of 45 questions, (c) designing the format: a 4-point scale, describing how often the item depicted the participants’ perception of his or her social competence (1 = never;2 = rarely, 3 = often; 4 = always), and (d) review performed by a six-member expert panel.

The 45 items selected were compiled into a pilot questionnaire, with 19 items using reverse scoring (i.e., a high scoremeans very low social competence). Examples of questions are: (a) I apologize when I think I am wrong (direct scoring) and(b) When people insult me I report to the supervisor (reverse scoring).

A pilot study with 30 young people with physical disability was performed, resulting in a Cronbach reliability coefficienta = .58. Omitting seven items enabled increasing the internal consistency to a = .75. The final version of the questionnaireincluded 38 items and acquired a Cronbach a = .78 with 100 participants of the study during the pretest and a value of .86with 90 participants during the posttest measurement.

2.2.4. Quality of Life (QOL) Questionnaire

This instrument was developed in English (Schalock, Keith, & Hoffman, 1990; Schalock, Keith, Hoffman, & Karan, 1989) forpersons with developmental disabilities, and was translated into Hebrew (Keith & Schalock, 1992). The authors reported aninternal consistency of the total score of .90, inter-rater reliabilities between .73 and .83, and a test–retest reliabilitycoefficient of .87. This instrument has criterion and construct validity in different populations, and was found useful forIsraeli participants with intellectual and physical disability (Almusny & Reiter, 1996; Hutzler, Zamir, & Fliess-Douer, 2004).QOL comprises four scales containing 10 items each, representing the domains of satisfaction, productivity, empowerment,and social integration. Each item was scored on a scale of 1–3 (total score range 40–120). For the purpose of the current studytwo items (from the scales) were omitted, one due to the request of the head research authority of the Ministry of Education,and the second due to insufficient factor loading in the reliability testing. After these changes the instrument had an overallCronbach a = .78 during the pretest with 100 participants, and .86 with 90 participants during the posttest measurement.

2.3. Description of the programs

Based on the physical activity involvement reported in the demographic questionnaire, participants were classified intofour cohort groups:

2.3.1. Competitive separate physical activity (COSPA)

Participants in this group trained at least three times per week, for 2 h each time (totaling six weekly hours or more),individually or in groups, and participated in regular competitive activity at a national and international level. Sportdisciplines practiced by these participants were swimming, table tennis, and hand-cycling. Participation in swimming andtable tennis did not require any specific accommodations, while participants in cycling used a hand-cycle as sportequipment.

2.3.2. Recreational separate physical activity (RESPA)

Participants in this group trained once to twice per week, in one to three activities lasting 30–45 min each (totaling up tothree weekly hours). Activities practiced by these participants included calisthenics, swimming, dancing, cycling, and table-tennis, which were primarily directed toward fun, leisure, and social contact. No accommodations were needed forswimming; in calisthenics the exercises were adapted to participants’ functional capability, mostly using mats; in dancingwheelchairs were used for mobility; in cycling hand-cycles were used.

2.3.3. No physical activity (NOPA)

Participants in this group did not train regularly in any kind of leisure time physical activity or sport.

Y. Hutzler et al. / Research in Developmental Disabilities 34 (2013) 579–587582

2.3.4. Reverse integrated basketball activity (RIBA)

Participants in this group trained once or twice per week (totaling up three weekly hours) in a reverse integrated settingof wheelchair basketball. They comprised four clubs that competed against each other under the framework of a juniorleague. The unique features of the participation in this group were: (a) the inclusion of participants without disability in thewheelchair basketball activity, with a ratio of up to 33%, (b) the inclusion of participants with limited arm function, and (c)the use of extensive adaptation for enabling the participants with low functional capacity to be effective during training andgame participation.

2.4. Procedure

The development and utilization of the questionnaires was controlled by review boards of the Haifa University and theMinistry of Education. All participants provided their written informed consent. Parents or guardians signed the consentform in the case of minors. The questionnaires were administered to all participants before and after a six-month interval.The questionnaires were administered by the second author, individually or in small groups, during leisure time settings at acommunity center, at school, or in the participants’ homes. Assignment of participants into the four groups was based on thedata on physical activity participation as reported in the personal questionnaire.

2.5. Statistical analysis

Data were processed and analyzed using the SPSS release 15 software (SPSS Inc., Chicago, IL, USA). The instruments’internal consistencies were evaluated prior to the final analysis. The PSC and QOL scales revealed acceptable reliability(Nunnaly, 1978; Cronbach a > .70). Demographic and functional differences between groups during the pretest wereassessed using a one-way ANOVA procedure, with post hoc paired Tamhane T2 analyses. The Levene test was used to accountfor inequality in group size. Where differences were found, variables were entered as covariates for the analysis of the maineffects (PSC and QOL).

The change in scores for each of the main effects across the six-month period was calculated for each group. In order toquantify the degree of change with respect to the baseline values, a percent change score was calculated in each group foreach outcome measure, and a general linear model (GLM) analysis of covariance (ANCOVA) was computed with group as thefixed factor on change in scores with LSD post hoc analyses where significance was established. Eta (h)2 effect sizes werecalculated in all ANCOVA procedures from SPSS F table outprints, and were interpreted according to the instructions ofPierce, Block, and Aguinis (2004) as medium (h2> .06 < .14); and large (h2> .13).

To identify the relationships between variables, Pearson correlations were computed between the outcomes of QOL andPSC during pre and post test measurements. In order to control for the degree of disability, the change scores of QOL and PSCwere correlated with FIM for the whole sample and in each group separately. Alpha level was considered significant at the .05level.

3. Results

3.1. Group characteristics

The distribution of age, gender, and cause of the participants’ disability across the four groups is presented in Table 1. Thedistribution of the participants’ preferred mobility pattern across groups is presented in Table 2. Participant dropout frompre to post test conditions occurred in the RIBA (eight participants) and the COSPA (two participants) groups. A one-wayANOVA did not reveal any significant differences between study groups in age or disease. However, gender was significantlydifferent between groups (Chi square [3] = 12.11). The COSPA and RIBA differed significantly (Fisher’s exact test = .016), withmore female participants in the COSPA, as well as between RIBA and NOPA (Fisher’s exact test = .002), with more femaleparticipants in the NOPA. FIM distribution significantly differed between groups after correcting the homogeneity ofvariance with the Levene test (F[3,96] = 12.45, p < .001). The post hoc Tamhane T2 paired analysis comparing between

Table 1

Mean and standard deviation (SD) of age, and distribution of gender and disability across groups.

Group FIM Age Gender Disability

Mean (SD) Mean (SD) N (%) N (%) N (%) N (%) N (%)

Males Females CP SCI NM

COSPA 86.47 (5.30) 19.5 (3.7) 7 (46.7) 8 (53.3) 8 (53.3) 3 (20) 4 (26.7)

RESPA 64.78 (18.89) 16.8 (3.0) 16 (69.6) 7 (30.4) 22 (95.7) 0 (0) 1 (4.3)

NOPA 61.23 (20.55) 16.6 (4.3) 9 (40.9) 13 (59.1) 18 (81.8) 2 (9.1) 2 (9.1)

RIBA 78.20 (11.29) 17.7 (4.3) 25 (83.3) 5 (16.7) 20 (66.7) 6 (20) 4 (13.3)

All 72 (18) 18.0 (3.95) 57 (63.3) 33 (36.7) 68 (75.6) 11 (12.2) 11 (12.2)

Remarks: CP: cerebral palsy; SCI: spinal cord injury; NM: neuromuscular disease; COSPA: competitive separate physical activity group; RESPA: recreationa

separate physical activity group; NOPA: no physical activity group; RIBA: reversed-integrated basketball activity group.

l

Table 2

Frequency (N) and percentage (%) distribution of mobility patterns across groups.

Group Mobility pattern

N (%) N (%) N (%) N (%) N (%) N (%)

Independent Crutches Walker Wheelchair Electric wheelchair Prosthesis

COSPA 9 (60) 1 (6.7) 1 (6.7) 2 (13.3) 0 (0) 2 (13.3)

RESPA 12 (52.2) 1 (4.3) 4 (17.4) 2 (8.7) 4 (17.4) 0 (0)

NOPA 7 (31.8) 1 (4.5) 6 (27.3) 3 (13.6) 5 (22.7) 0 (0)

RIBA 16 (53.3 3 (10) 4 (13.3) 7 (23.3) 0 (0) 0 (0)

All 44 (48.9) 6 (6.7) 15 (16.7) 14 (15.5) 9 (10) 2 (2.2)

Remarks: COSPA: competitive separate physical activity group; RESPA: recreational separate physical activity group; NOPA: no physical activity group;

RIBA: reversed-integrated basketball activity group.

Table 3

Pre and posttest means (M) standard deviations (SD) change and % change from pretest to posttest by group and measure.

Group QOL PSC

N Pre Post Change % Pre Post Change %

COSPA M 100 101.07 1.07 1.07 117.73 117.73 0 0.00

15 SD 8.07 7.76 5.12 12.25 14.1 7.1

RESPA M 90.42 91.78 1.36 1.50 106.39 109.39 3 2.74

23 SD 11.94 10.95 7.9 14.63 15.25 10.2

NOPA M 93.95 93.73 -0.18 -0.19 112.4 109.86 -2.54 -2.31

22 SD 9.96 12.27 6.79 10.97 12.31 6.64

RIBA M 95.1 103.87 8.77 9.22 113.36 125.93 12.57 9.98

30 SD 7.7 6.42 9.67 12.79 10.34 13.66

Remarks: QOL: Quality of Life Questionnaire; PSC: Perceived Social Competence questionnaire; COSPA: competitive separate physical activity group; RESPA:

recreational separate physical activity group; NOPA: no physical activity group; RIBA: reversed-integrated basketball activity group.

Y. Hutzler et al. / Research in Developmental Disabilities 34 (2013) 579–587 583

groups revealed that RIBA had higher FIM values than RESPA (mean difference = 13.42, SE = 4.45, p < .03) and NOPA (meandifference = 13.42, SE = 4.45, p < .0316.97, SE = 4.84, p < .009), but lower values than COSPA (mean difference = �8.26,SE = 2.47, p < .01). Based on these findings, FIM and gender were entered as covariates into the analysis of varianceperformed on the outcome measures.

3.2. Group differences by outcome measures

Table 3 presents the mean and standard deviations of outcomes of the pre and post tests as well as their differences, andthe percent of change from pretest scores by group for QOL and PSC. Table 4 presents the GLM ANCOVA results obtained onthe main effects with the fixed factor group and the covariates FIM and gender. All corrected model effects were significant.Effect sizes (h2) by Group are also presented, as well as post hoc comparisons between groups where significant effectsappeared. In the section that follows, the outcomes of the GLM ANCOVA computed between groups across each outcomemeasure will be presented.

3.2.1. QOL

A significant group effect was obtained (F[3,89] = 3.54, p < .0001), with a medium effect size (Table 4). The LSD post hocpaired analysis revealed that the RIBA significantly differed from all other groups. The one-way ANOVA on change valueswith LSD post hoc revealed a significant difference with the RIBA change score, with 8.77% significantly (p < .001) higher thanall other groups (range �0.18 through 1.36%). This change enabled the RIBA group to close the gap in QOL scores observed atthe pretest (F[3,89] = 3.1, p < .03) between the COSPA and the other groups.

Table 4

GLM ANCOVA results, with F, significance (P), and effect sizes (h2) by group, and covariates sex and FIM across outcome measures.

QOL PSC

F[3,89] P h2 F[3,89] P h2

Corrected model 5.51 .0001 6.18 .0001

Group 3.54 .0001 .061 9.07 .0001 .069

LSD post hoc RIBA > COSPA; RESPA; NOPA RIBA > COSPA; RESPA; NOPA

FIM 1.83 NS .0014 2.18 NS .014

Gender 0 NS 0 0.022 NS 0

Remarks: QOL: Quality of Life Questionnaire; PSC: Perceived Social Competence questionnaire; COSPA: competitive separate physical activity group; RESPA

recreational separate physical activity group; NOPA: no physical activity group; RIBA: reversed-integrated basketball activity group; NS: non-significant

:

.

Y. Hutzler et al. / Research in Developmental Disabilities 34 (2013) 579–587584

3.2.2. PSC

Similar to QOL, a significant group effect (F[3,89] = 907, p < .0001) was obtained with a medium size effect and nosignificant covariate effects. The LSD post hoc tests on change scores revealed that the RIBA, with a 9.98% change, wassignificantly higher than all other groups (range �2.31 to 2.34%). The NOPA group depicted a slight decline and the COSPAgroup no change in PSC. The interaction of group and time in RIBA outcomes was so substantial that while during the pre testthe COSPA depicted the highest values in PSC and in QOL, after the intervention the RIBA exceeded the results of the COSPAand became the group with the highest mean value.

The covariates: gender and FIM were non significant in all outcome variables.

3.2.3. Correlations

A Pearson correlation analysis performed on all participants between outcome measures at pre and post tests, revealed astrong relationship between QOL and PSC (r = .64, p < .0001 and r = .655, p < .0001, respectively). The correlations of changescores in QOL and PSC with FIM were non significant. Specific correlations performed on change scores with FIM in eachgroup revealed a significant moderate negative correlation between PSC and FIM in the RIBA (r = �.47, p < .001).

4. Discussion

The purpose of this study was to examine the contribution of different physical activity and no physical activityframeworks during a period of six months on QOL and PSC in young people with developmental physical disabilities. Inaddition, the statistical analysis enabled to control, within the limits of the relatively small sample size, for personal andenvironmental variables such as functional level, gender, group activity, and competitive activity. The outcomes of this studydid not support a significant benefit of participation in all three physical activity conditions, but did reveal significantbenefits of the unique program conditions exercised in the RIBA group.

4.1. General effects of physical activity participation

Evidence supporting an improved perception of psychosocial attributes in physical activity participants with a disabilityhas been reported in cross-sectional studies pertaining to improved self-efficacy in wheelchair tennis (Greenwood &Dzewaltowski, 1990) and wheelchair-rugby participants compared to non-participants (Adnan, McKenzie, & Miyahara,2001), as well as in a few small-scale longitudinal studies (e.g., Geron & Dunkelman, 1982; Monnazzi, 1982). Nonetheless,our findings (see Tables 3 and 4) did not confirm a general effect of physical activity on the QOL and PSC, since the changes inCOSPA and RESPA outcomes was not significantly different from these of the NOPA group.

These outcomes appear to contradict expressions of empowerment through competitive and recreational sport practice(Hutzler, 1990), increased social initiative and activity based on individual experiences of recreational athletes withdisability who were linked to the development of their social self (Blinde & McClung, 1997), as well as contradicting anormalizing experience reported in recreational activity for children with physical disabilities (Taub & Greer, 2000), basedon qualitative analysis of in-depth interviews. One potential confounding variable that might explain the differentoutcomes is the fact that the vast majority of our sample was composed of participants with a congenital disability. Athleteswith this type of disability must cope with the effect of disability throughout their childhood and adolescence, and havedemonstrated poorer outcomes of psychosocial well-being than athletes who acquired their disability later in life(Campbell, 1995).

4.2. Specific effects of reversed integration in basketball

The most important finding of the current study is the specific value of participation in the reverse integrationcondition. The RIBA group had significant better outcomes after the six-month period monitored, than both the otherphysical activity groups in QOL and PSC. This finding is strengthened when taking into account that the total training timeof the COSPA was greater than that of the RIBA or the RESPA (six compared to three hours on average). We are not awareof any other studies measuring psychosocial outcomes of RIBA activity or any other sport-specific reverse integration.Several principles utilized during the RIBA program may have facilitated this effect: (a) using the wheelchair as specificsport equipment. In contrast to the other physical activity groups, the RIBA group specialized in an activity where thewheelchair functioned as the primary mobility context. Therefore, the typical identification of a wheelchair withdisability may have been replaced with a sport-related identification, facilitating the participants to ‘‘gain an identity andtake pride in being healthy, active, and socially engaged’’ (Craven et al., 2006, chap. 3, p. 52); (b) adapting the equipmentand rules while utilizing the twin baskets scoring modality. The adding of a low-height basket to enable participants withsevere disability to score baskets was proposed in Japan (Suyama et al., 1998; Uchida et al., 1994). This option waseffectively used in the RIBA group, facilitating the functionally less able participants to be and to perceive themselves assuccessful; (c) classification and rule adaptation. Wheelchair basketball is a group activity played under classificationrules, challenging the social role of participants with limited arm functionality. Our adapted classification and rulebookenabling participants with limited arm functionality to stay in a zone, covered only by other players with the same degreeof function, probably facilitated the outcomes and perceived benefits of these participants, leading to a notion of QOL and

Y. Hutzler et al. / Research in Developmental Disabilities 34 (2013) 579–587 585

PSC; (d) Participation in a normative and desirable activity. Basketball is highly valued as a legitimate leisure-timeactivity among individuals with and without disability. As such, it is supported by a variety of social agents facilitatingmotivation to participate in an activity, such as parents, siblings, friends, and educators. The addition of peers without adisability may have increased the range of social demands and role models with whom the participants with disabilitywere able to identify, thus facilitating a perception of group unity and teamwork (see Blinde & Taub, 1999). Our resultsare supported by a recent study of Spencer-Cavaliere and Peers (2011), who explored how competitive female athleteswith a disability experienced reversed integration in Canada, and suggested that participation in this context contributedto their positive athletic identities.

While the principles described here may not always be applicable within reverse integration environments, they shouldbe considered by practitioners as useful strategies.

4.3. Functional ability

Several studies performed with young people with cerebral palsy (e.g., Bjornson, Belza, Katrin, Logsdon, & McLaughlin;Palisano, Koepland, & Galuppi, 2007) demonstrated a relationship between level of functional ability and participation insport and other daily leisure and physical activities. This finding supports the notion that those with severe restrictions infunctional ability are less likely to benefit from sport participation, apparently due to the interplay of physical andpsychological barriers. However, Meijer, Sinnema, Bijstra, Mellenbergh, and Wolters (2000) did not find an effect offunctional ability on interaction with peers within a group of physically disabled individuals. In addition, Fliess-Douer,Hutzler, and Vanlandewijck (2003) did not find a difference across functional classification categories in wheelchairbasketball players with regard to their goal perspective. In our study, functional ability as measured with the FIM did nothave a general effect on QOL and PSC, but did have a negative relationship with PSC in the RIBA group. Based on this finding itmay be suggested that the RIBA modality enabled the less-functional participants to gain more on PSC. This outcome couldprobably be linked to the unique adaptations (i.e., reverse integration, twin baskets, using wheelchairs; adapted rulebook)performed within this modality.

4.4. Limitations

Several limitations may challenge the interpretation of outcomes in the present study.

4.4.1. Dropouts

Eight of the dropouts were observed in the RIBA group, while there were only two in the COSPA and none in the RESPAgroups. The larger dropout rate within the RIBA group may be linked to social reasoning, contending that the social context ofthis group resulted in excluding those who did not benefit from the activity. Such an argument may challenge the results,suggesting that the attributes of the remaining participants were more favorable toward benefiting from this activity thanthe attributes of those who dropped out. However, monitoring of dropouts suggested that most of the reasons for theirdiscontinuing the activity consisted of transportation problems and other technical, rather than social, barriers. In addition,t-tests performed between the original and the final samples in each group revealed non-significant differences in alloutcome measures.

4.4.2. Demographic and functional differences in the groups’ composition

Some differences were found at pretest in regard to gender, functional ability, and other social context variables, whichcould have affected the results. However, within the framework of our sample, no gender or function effect was found inregard to results in the outcome measures.

4.4.3. Outcome measures

Due to technical limitations, only surveying methods were used in this study. Direct observation of social activity mighthave supported or contradicted the perceived benefits reported in the RIBA and other physical activity groups. Future studiesare encouraged to include fitness or game observation methods. Another desirable methodology would be that of in-depthinterviewing of participants in the activity, as was done for separate competitive and recreational activities by Goodwin andcolleagues (Goodwin et al., 2009; Goodwin, Krohn, & Kuhnle, 2004; Goodwin & Staples, 2005).

4.5. Conclusions and recommendations

This study assessed the impact of participation over a six-month period in three different types of sport programs,on the psychosocial attributes QOL and PSC of young people with physical disability compared to sedentary controls.This study exposed the specific contribution of the RIBA modality compared to participation in separate competitiveand recreational sport activities. Low functional ability did not constrain the favorable effects of sport participation.Future studies are encouraged for replicating the effects of different modalities of sport participation on the psycho-social attributes of larger samples, including athletes with congenital disability as well as those with acquireddisability.

Y. Hutzler et al. / Research in Developmental Disabilities 34 (2013) 579–587586

Acknowledgements

The Reverse Integrated Basketball Activity program was assisted by a grant of the Fund for Demonstration Projects, whichwas established with the aim of encouraging organizations to develop new initiatives in the area of community socialservices within the Division for Service Development of the Israel National Insurance Institute.

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