Well-Being, Resilience and Social Support of Athletes with Disabilities: A Systematic Review

Sport for people with disabilities appears to play a positive role in the well-being, resilience and social support of athletes with disabilities. Thus, this systematic review aims to evaluate the effect of adapted sport on the well-being, resilience and social support in a population with disabilities. The Pubmed, Web of Science, Scopus and SportDiscus databases were used, with several descriptors and Boolean operators. A total of 287 studies were identified through searching the databases. After the data extraction process, twenty-seven studies were included for analysis. In general, these studies show that adapted sport has a positive impact on the levels of well-being, resilience and social support resources for people with disabilities, contributing to their personal development, quality of life and integration into society. Considering the impact on the variables studied, these results are important to support and encourage the development of adapted sport.


Introduction
Although there are barriers to practice (including the challenge of inclusion, limited programs, the inaccessibility of facilities, difficulty in transport and even a lack of social support in various aspects [1,2]), sport, as a tool that promotes health, quality of life and social integration, presents itself as a benefit for people with disabilities, namely in selfconfidence [3][4][5], satisfaction and quality of life, self-esteem [3][4][5][6][7], a reduction in suicidal tendencies, a more independent attitude and the motivation to continue evolving [3,4].
On the other hand, the Paralympic Movement has been considered a platform for presenting the abilities of people with disabilities while serving as a catalyst for their rights, ensuring integration, equal opportunities and accessibility [3]. Thus, in addition to issues related to the performance of participants, attention has also been dedicated to understanding the processes underlying the measurement of happiness, leading to well-being being the object of study in the most diverse areas and populations [8,9]. Wellbeing has been studied in two streams, one according to happiness (subjective well-being representing hedonic well-being) and another according to human potential (psychological well-being representing eudaimonic well-being) [10][11][12][13][14]. Eudaimonia represents living life according to one's own potential or internal virtue [13]; it derives from personal activities that promote self-realization through the realization of personal potentialities and the (especially in youth sport) through their positive influence on various factors. They also realized that it is important to adjust the athlete's support pattern throughout their career as needs change.
To the best of our knowledge, no study has systematically reviewed the literature on the factors associated with the impact of adapted sport on these variables. Focusing solely on people with disabilities, the purpose of the present systematic review was to identify and assess the peer-reviewed scientific literature on the relationship between sport practice and (i) well-being; (ii) resilience; and (iii) social support.

Eligibility Criteria
The present systematic review was performed according to the PRISMA protocol [53,54] and the methods suggested by Bento [55]. The protocol was registered in PROSPERO, with the following number: CRD42022362330 (https://www.crd.york.ac.uk/prospero/export_ details_pdf.php, accessed on 13 December 2022).
The PICOS strategy [56,57] was defined as follows: (i) "P" (Patients) corresponded to participants with any type of disability, of any age, gender, ethnicity or race; (ii) "I" (Intervention) corresponded to a sports program, implemented in the population mentioned before, regardless of the intervention period; (iii) "C" (Comparison) corresponded to the comparison between those practicing and those not practicing sports or pre postintervention program; (iv) "O" (Outcome) corresponded to levels of well-being, resilience and social support as the primary or secondary variables of focus; (v) "S" (Study design) corresponded to intervention studies, randomized controlled trials (RCTs) or not (non-RCTs) and cross-sectional studies.

Information Sources and Research Strategies
The systematic search for articles was conducted between September and 19 December 2022, in four electronic databases: PubMed (all fields), Web of Science, Scopus and SPORTDiscus (title, abstract and keywords). We searched all studies published in English until 31 December 2022.
The reference lists of all selected articles were independently screened to identify additional studies missed in the initial search. The following indexed search descriptors were used across all databases in the following formats: "cerebral palsy" OR "motor disability" OR "motor disorder" OR "physical disability" OR "vision impairment" OR "visual impairment" OR "vision disability" OR "vision disorders" OR "intellectual disability" OR "mental retardation" OR "intellectual disabilities" OR "intellectual developmental disorder" OR "intellectual impairment" OR "hearing impairment" OR "hearing disability" or "hearing loss" OR "multiple disabilities" OR "para athletes" OR "para-athlete" OR "Paralympian" OR "Paralympians" OR "paralympic athletes") AND sport* AND ("social support" or "social influence" OR "well-being" OR "resilience" OR "resiliency".

Inclusion Criteria
To be included in this systematic review, studies had to meet the following criteria: (i) articles published in English by 31 December 2022, regardless of country; (ii) intervention studies, RCTs and non-RCTs and cross-sectional studies; (iii) intervention studies with a sports programme; (iv) individuals with disabilities, of the most varied types; and (v) studies with individuals of any age group, gender, race or ethnicity.

Exclusion Criteria
For this review, the following exclusion criteria were considered: (i) studies published before 2001; (ii) studies with participants with other pathologies (e.g., mental illnesses, degenerative diseases); (iii) studies that did not describe the intervention protocol; (iv) studies in which the intervention was not only a sports programme (example: physical exercise + nutrition).

Data Extraction Process
The search was carried out independently by two researchers. In the first phase, all searched manuscript bibliographies were organised using the EndNote software and so duplicated studies were eliminated. Subsequently, the studies were analysed and selected based on the defined inclusion and exclusion criteria. Subsequent to the completion of this process, the results were compared by the researchers.
After reading the full text of all the selected studies, according to the previously defined eligibility criteria, one of the researchers identified the most relevant information published in each study and entered it into a preliminary characterization table (authorship, country reference, objectives, participants, modality, assessment techniques, results and quality score).

Selection of Studies
The initial search conducted in the four databases revealed a total number of 287 identified articles. In the first phase, and after reading the titles and abstracts, 81 were removed for being duplicates and of the 206, 165 were excluded after applying the inclusion and exclusion criteria previously defined for this systematic review. This resulted in 41 articles, of which 2 we were not able to access. Of the 39 articles assessed for eligibility, after a reading of the articles, a sample of 27 studies was considered for analysis, as represented in the PRISMA flowchart ( Figure 1).

Data Extraction Process
The search was carried out independently by two researchers. In the first phase, all searched manuscript bibliographies were organised using the EndNote software and so duplicated studies were eliminated. Subsequently, the studies were analysed and selected based on the defined inclusion and exclusion criteria. Subsequent to the completion of this process, the results were compared by the researchers.
After reading the full text of all the selected studies, according to the previously defined eligibility criteria, one of the researchers identified the most relevant information published in each study and entered it into a preliminary characterization table (authorship, country reference, objectives, participants, modality, assessment techniques, results and quality score).

Selection of Studies
The initial search conducted in the four databases revealed a total number of 287 identified articles. In the first phase, and after reading the titles and abstracts, 81 were removed for being duplicates and of the 206, 165 were excluded after applying the inclusion and exclusion criteria previously defined for this systematic review. This resulted in 41 articles, of which 2 we were not able to access. Of the 39 articles assessed for eligibility, after a reading of the articles, a sample of 27 studies was considered for analysis, as represented in the PRISMA flowchart ( Figure 1).
The full text was critically read to confirm that the study fulfilled the inclusion criteria. Twelve studies were excluded, which resulted in a final sample of 27 scientific studies that formed the basis of the present study, as shown in the following Table 1.
The full text was critically read to confirm that the study fulfilled the inclusion criteria. Twelve studies were excluded, which resulted in a final sample of 27 scientific studies that formed the basis of the present study, as shown in the following Table 1. The results indicate that there is an association between involvement in the SO and reduced stress, increased quality of life and higher self-esteem.
The hypothesis of increased social networks was not demonstrated. The findings provide further evidence of a positive association between sport involvement and increased psychological wellbeing, especially for those involved in the SO. The most important personal characteristic supporting Paralympic athletes' self-realization in sports is their psychological hardiness, since all four of its indicators have sufficiently close correlations with three of the four self-realization indicators-"Satisfaction with own sports career", "Fastness of sportive goal setting after achievement of a previous one" and "Reaching of top-achievements in sports". Paralympic athletes' rapidity in sportive goal setting after achievement of a previous one is significantly related to all ten psychological well-being scales, and their clarity of perception of own future in sports correlates with five scales. The well-being needs and strengths of para-athletes differed across gender, sport, level of competition and nature of impairment. Well-being strengths were perceived to increase as athletes increased their level of competition, and included personal growth, optimism, strong social support networks and contributing to multiple communities.
Examine the resilience process of sport participants with acquired spinal cord injury, and the role of sport participation in the resilience process N = 12 men with aged 21 to 41 years Disabilities: physical

Wheelchair rugby Semistructured interviews
The development of resilience is a multifactorial process involving pre-existing factors and pre-adversity experiences, disturbance/disturbing emotions, various types and sources of social support, special opportunities and experiences, various behavioural and cognitive coping strategies, motivation to adapt to changes and learned attributes or gains from the resilience process. Athletes perceive a positive affect superior to negative affect. Regarding social support, the perception of support by the coach is the one with the highest value. The bivariate correlation was observed between life satisfaction and positive affect (medium), between positive affect with social support from parents (high) and between positive affect with social support from friends (medium). Resilience displayed a negative and significant association with the negative affect (high). Importance of social support types differed according to skill level, playing level, years played and future playing intentions.

Good
All studies presented followed a cross-sectional methodology. By analysing the table, we can see that nine studies were classified as "poor", seven studies as "fair" and twelve studies as "good". No article was classified as "excellence".

Evaluation Protocols/Instruments/Techniques
The studies analysed used different instruments for the same variables: interviews, questionnaires, validated scales and adapted scales.
The main objective of this study was to identify and understand what has been studied about well-being, resilience and social support in disabled athletes practicing a sport modality. The results confirm that these variables have been the focus of researchers' attention, especially in the last decade.
Our research resulted in 21 studies that studied well-being, 9 studies that studied resilience and 12 studies that studied social support in athletes with disabilities. Together, well-being and social support were studied in eight studies, well-being and resilience in six studies, resilience and social support in three studies and only two studies studied the three variables together.
In the study of the perception of well-being in children and young people with physical disabilities practicing sport, positive perceptions were observed in all domains, including the children with disabilities showing higher values of perception of well-being than their parents. These results are extremely important and should be taken into account, as it is the parents who make decisions regarding their children's practices, and it is very important to be aware of this detail [81].
In terms of psychological well-being, the positive impact of practicing sport on athletes with disabilities is consistent [68][69][70]76,79,80]. The perception of psychological well-being seems to have a negative correlation with increasing age and persons with congenital disabilities showed higher well-being scores compared to persons with an acquired disability. This may be due to a greater difficulty in adapting to and accepting their own disability [79]. However, in these cases, this difficulty was mitigated by sport in competition, as in the Paralympic group the scores of athletes with congenital and acquired disabilities were similar [79]. Paralympic athletes showed results in line with the standards of the general population. They claim that this is due to sport opportunities. All components of the psychological well-being of Paralympic athletes are significantly higher than students with disabilities who do not participate in sport [69]. Psychological strength is the most important factor supporting self-realization. On the other hand, they determined that two of the four indicators of the self-realization of these athletes are significantly related to the indicators of psychological well-being, purpose in life and meaning in life [70].
Considering the importance and focus of our study on subjective well-being, it was important to note the positive impact of this variable in the various studies [7,[71][72][73]82].
Adapted sport presents itself as an enhancer of well-being in athletes with physical disabilities. In studies that analysed subjective well-being, athletes expressed high positive affect and low negative affect [74,81], as well as a significant relationship between positive affect and a strong relationship with peers [81]. High levels of life satisfaction have been associated with playing sports and the experiences provided [7,[72][73][74]. These results reinforce the importance that the practice of sports seems to have on the perception of subjective well-being, both in its cognitive dimension (satisfaction with life) and its emotional dimension (positive and negative affect) and are in line with what has been reported in the literature [24,25].
Although the levels of well-being were perceived to be gradually positive as the athletes increased their level of competition, they also concluded that they had well-being needs, suggesting an interaction between physical pain, emotional regulation, lack of purpose outside of sport and lack of self-acceptance. Others reported negative emotions, frustration, bitterness and uncertainty, which may have to do with the fact that they are elite athletes who feel poorly supported and afraid of losing their careers because they do not have the financial capacity to train as they would like to. If these athletes reported emotional unbalance as a need in terms of well-being at the end of a major competition, such as the Paralympic Games, including feelings of loss, lack of guidance and depression, it was also perceived that when strong well-being was manifested, it was associated with personal growth, optimism, strong social support networks and contribution to various communities. Personal growth and optimism have been related, as a result of life satisfaction, with the ability to deal with what life provides in a positive way [71].
These results support our belief in the importance of adapted sport in contributing to well-being in people with disabilities.
The most common limitations of the studies analysed in this systematic review are that they include a restricted group, such as participants from a single sport or athletes from a single country or state [59,63,72,82,83], and no experimental studies were found for the well-being variable. It is suggested that in future investigations, comparisons of people with and without motor disabilities, other types of disabilities, other sports, and analysis of the existing differences as well as experimental studies should be considered [83], to evaluate the impact of sports practice on the variables.

Resilience
Satisfaction with life has been studied with other variables such as resilience, with a positive relationship observed between the two variables. In the analysed studies, it is a consistent conclusion that athletes with higher levels of resilience have higher life satisfaction [7,72,73]. Resilience is mentioned as a significant predictor of life satisfaction and sport involvement [73].
Athletes with disabilities who play sports have demonstrated high levels of resilience qualities: life satisfaction, optimism, resilience and social focus [7].
Resilience has been widely studied as a quality present in people with disabilities in the sense that they are people with resources that allow them to protect themselves and thus overcome the adverse effects of exposure to risk [84] and, in the case of this systematic review, this includes practicing sport [7,47,60,61,[72][73][74]77,78].
Individuals with spinal cord injury and myelomeningocele (spina bifida) showed higher levels of resilience compared to the lower resilience observed in people with cerebral palsy. This result can be explained by the functionality existing in each disability. Thus, athletes who presented high levels of resilience showed higher levels of quality of life [61]. Higher levels of resilience were observed in people with disabilities and correlated especially with their own relationship with their body and sexual esteem. They concluded that sport has the ability to improve athletic identity and self-esteem, causing people with disabilities who participate in sport to develop self-confidence to face and cope with their own disability and its challenges [77]. The development of resilience in athletes with spinal cord injury is a multifactorial process that involves pre-existing factors and experiences, unpleasant emotions, various types and sources of social support that generate opportunities and special experiences that lead to different cognitive and behavioural strategies and, consequently, motivation to adapt to change [47,71].
We observed that paralympic athletes, as a rule, are conscious that their ability to overcome difficulties is related to their physical and mental experiences and challenges related to disability. They consider that the development of these resilient characteristics and ability to cope with physical and emotional pain comes from the constant exposure to pain and stress experienced [78]. The wheelchair tennis athletes who participated in the study by Richardson et al. [80] highlighted an important detail. Participation in this sport strengthens one's resilience, which then transfers off the court. By overcoming challenges as players, it allows them to develop resilience which they can apply in their daily lives.
Like the well-being variable, we noticed that no experimental study on resilience was found in the present review.
In the studies reviewed, we found some limitations of the study of resilience, such as the different ways and different moments of resilience assessment between studies, resilience not being measured in relation to an adverse event and some researchers see limited value in assessing resilience in the absence of an adverse situation [72,73]. Additionally, the condition of the athlete's disability, congenital or acquired, may influence resilience levels [47]. Samples with multiple sports included may make it difficult to generalise findings due to the nature of and differences between the specific sports [78].
Future studies may assess resilience by type of disability, congenital or acquired, and, when acquired, by the relationship with the time it was acquired, as it may be different depending on the condition and context.

Social Support
We perceived that self-esteem and social support have a reciprocal relationship, low self-esteem is associated with not seeking support and a greater tendency for misconduct. Involvement in sport for people with intellectual disabilities has added value by acting as an intervention to increase resilience [63]. Athletes who have higher levels of resilience and social support show more commitment to their sport [61].
There is a consensual agreement on the importance of social support, mainly from family, friends and coaches [47,66,74,75,83]. In this systematic review, the first study to address the issue of social support was prepared by Swanson and Zhao [83]. They reported that social support is essential to build teamwork, which provides support in the various challenges and tasks that are inherent and adjusted to the characteristics and needs of the athlete so that they can be successful [83]. Social support is identified as one of the most important factors in dealing with challenges and recovering from adversity; it is fundamental to the process of developing resilience. The sources of social support are multiple, from family, therapists, colleagues and coaches, among others [47].
Sport experiences provide an improvement in social skills, which in turn is related to well-being and social support. The efforts and reinforcing approval they receive from coaches, parents and peers provides athletes with a sense of social acceptance [66,74].
Athletes who experienced higher levels of social support inside and outside of sport competitions showed higher levels of engagement with their sport [60].
Recently, Aichtinson et al. [59] developed the model "The Podium Illusion", where they identified twenty-five forms of support mentioned by athletes with disabilities. Of the various supports mentioned, they highlighted the importance of the vital role of "staff" in enhancing their training and performance, including coaches, psychologists, physiologists, nutritionists, biomechanists, etc. Family, friends and other performance agents were associated with the necessary and indispensable support by the provision of mental health care and overall happiness. This provided assurance of well-being allowed a perception of improvement in the athlete's performance. The coach was valued as an inspirational figure of motivation, providing improvements in levels of self-esteem and well-being, resulting in improved overall performance. The strong relationship with the coach is extremely important for these athletes [59].
The results found in the analysed studies are significantly important. There is a consensus that social support from family, friends and coaches has a decisive impact on the sport practice of athletes with disabilities [59,60,63,75,76,83]. It is suggested that it is beneficial to analyse the coaches' perception of the social support of their athletes [75].
One of the limitations in studying social support is the diversity of assessment tools, given the various components and characteristics of social support. Future studies should focus on only one instrument or should carry out subgroup analyses. The timing of the assessment of social support can be considered a limitation [75]. As with the study of resilience, the athlete's disability status, congenital or acquired, may influence levels of social support [78]. At the same time, future studies may assess social support by type of disability, congenital or acquired, and when acquired, by the relationship with the time it was acquired and the respective needs.
Furthermore, it seems pertinent that future studies focus on the relationships that can be established between these all variables, particularly regarding adapted-sports athletes (for example, the analysis of the effect that social support and resilience can have on the well-being of athletes).

Conclusions
From the analysis of the studies included in this systematic review, we can conclude that sport seems to have a positive role in the well-being of athletes with disabilities in the various domains.
All studies that studied well-being revealed positive perceptions between the sport practice of disabled people and this variable.
At the same time, these studies confirm and strengthen the relationship between life satisfaction and resilience, in the sense that athletes with higher levels of resilience have greater life satisfaction. Consequently, they also present greater involvement and commitment to their sport.
We can observe that there are several studies that strengthen the importance of the practice of sports as a significant social opportunity that helps in the resilience process of people who face adverse situations derived from their own disability.
We also concluded that social support for these athletes is extremely relevant for the improvement of their career. Family, friends and other social agents were associated with indispensable support for the possibility of sports practice. These results confirm that the participation of educated and trained people to support the development of these athletes' careers will consequently have positive results.
We consider these results important to support and encourage the development of adapted sport, which should be taken into consideration by policymakers and other organizations due to the positive impact that it has on contributing to levels of wellbeing, resilience and social support resources in people with disabilities, contributing to improvements in their personal development, their quality of life and their integration into society.

Conflicts of Interest:
The authors declare no conflict of interest.