1.4.1. Cardiovascular endurance

Cardiovascular endurance refers to the ability of the heart, lungs, and circulatory system to supply oxygen efficiently during prolonged physical activity, which is essential for overall health, reducing risks of conditions like heart disease, and improving quality of life. When developing cardiovascular endurance, training prescriptions must respect the foundational principles of overload, progression, specificity, reversibility, and individualization [10-11].

For wheelchair users and people with sensory impairments (such as visual, hearing, or tactile sensitivities), developing this requires tailored approaches that account for mobility limitations and sensory needs. These adaptations ensure safety, accessibility, and effectiveness, drawing from evidence-based guidelines. Key principles include customization, gradual progression, and incorporation of assistive cues or equipment to overcome barriers like limited spatial awareness or communication challenges.

Core rules and guidelines are:

Frequency: Aim for 2–3 sessions per week initially, building to 3–5 as endurance improves. This prevents fatigue and allows recovery, which is crucial for wheelchair users prone to upper body strain. Sessions can be home-based or community-led for accessibility.

Intensity: Start at low to moderate levels (e.g., 30–40% of heart rate reserve, where you can talk but not sing) and progress to vigorous (e.g., high-intensity intervals at 90% effort). Monitor using perceived exertion scales (e.g., Borg scale) adapted for sensory needs—verbal descriptions for visual impairment or visual charts for hearing impairment. Avoid high impact on joints; use heart rate monitors with audio feedback if needed.

Time (Duration): Begin with 10–20 minute sessions, gradually increasing to 25–60 minutes. Break into shorter intervals (e.g., 5–10 minutes) with rests to build tolerance. Total weekly goal: at least 150 minutes of moderate aerobic activity, adjusted for individual capacity.

Type of activity: Focus on upper-body or seated exercises that elevate heart rate without requiring standing. Adapt activities according to everyone’s condition, abilities, and available support technologies. Incorporate adaptive equipment like handcycles or resistance bands. Use sensory adaptations: tactile markers for positioning, audio cues (e.g., beeps for timing) for visual impairments, or visual timers for hearing impairments.

Progression and overload: Gradually increase challenge (e.g., add resistance or duration every 1–2 weeks) to stimulate adaptation, but monitor for signs of overtraining like shoulder pain. Use motivational tools like goal-setting apps with voice output for sensory accessibility. Sessions should emphasize continuous movement and gradual load increases.

Recovery and safety: Include warm-ups (e.g., gentle arm circles) and cool-downs (stretches). Allow 48 hours between intense sessions for recovery. Hydrate well and use supportive environments like pools for buoyancy. Incorporate behavioural strategies like self-monitoring via apps or journals adapted for sensory needs.

Monitoring and support: Track progress with adaptive tools (e.g., talking heart rate monitors). Engage in group sessions for social benefits, using inclusive communication methods. If impairments affect balance or perception, partner with a guide or use stable equipment.

Examples of adapted activities

The parameters of physical effort can direct training methods toward different components of fitness:

A. Cardiovascular Endurance: Walking, running, swimming, cycling, dancing, aerobic sports, and team games are effective alternatives for developing cardio-respiratory endurance.

B. Muscular strength and endurance: Gymnastic exercises performed individually, with a partner, or in groups — whether free exercises, with portable equipment, on machines or specialized installations, in gym facilities, or through specific methods such as calisthenics — serve as effective solutions for building muscular strength and endurance.

Both categories, through caloric expenditure or by increasing muscle mass, contribute to the harmonization of body composition. Examples of fundamental strength exercises are push-ups, squats, pull-ups, chin-ups, plank, handstand, lunges, dips, burpees.

C. Flexibility and muscle elasticity: Individual or partner-based exercises, performed on static, dynamic, or combined apparatus and installations, can be targeted toward improving muscular elasticity and overall flexibility.

Here’s a table of suitable activities, with sensory adaptations and how they build endurance (Table 2).

Activity	Description and rules for endurance development	Sensory adaptations
Hand cycling	Use an arm ergometer or handcycle for upper-body propulsion. Start at low resistance for 10–20 min, progressing to intervals (e.g., 1 min high effort, 2 min recovery).	Audio pacing apps for visual impairment; visual speed displays for hearing impairment.
Wheelchair propulsion/Sprinting	Push wheelchair on a track or treadmill. Build from steady pacing to sprints; aim for 20–30 min sessions, 2–3x/week.	Tactile ground markers or verbal guidance for navigation if visually impaired.
Seated aerobics or circuit training	Perform arm movements, punches, or resistance band pulls in sequences with minimal rest. 25–45 min circuits, increasing reps over time.	Rhythm-based music with vibrations for hearing impairment; descriptive audio instructions.
Adapted swimming or water aerobics	Use pool buoyancy for low-impact cardio; swim laps or do arm strokes. 20–40 min, focusing on continuous motion.	Flotation aids with tactile handles; auditory signals for turns if visually impaired.
Para rowing or adapted rowing machine	Row using upper body on an adapted machine. Moderate intensity for 30 min, 2–3x/week, with progressive overload.	Visual feedback screens or audio cues for stroke timing.

These rules and activities promote cardiovascular health while addressing unique challenges, leading to benefits like improved heart function, reduced disease risk, and enhanced mental well-being. Consistency is key, and programs can be extended to 6–12 months for optimal results.

1.4.2. Muscular strength

Muscular strength is the ability of muscles to exert maximum force in a single effort, which is vital for daily tasks like propulsion, transfers, and maintaining posture in wheelchair users. For those with sensory impairments (e.g., visual, hearing, or tactile), building strength enhances independence, reduces injury risk, and improves quality of life, but requires adaptations for safety and accessibility [12].

Evidence shows strength training can improve muscle tone, joint protection, and overall well-being, even with disabilities like spinal cord injuries or neuromuscular conditions. These rules are tailored using the FITT principle (Frequency, Intensity, Time, Type), with emphases on upper-body focus (due to wheelchair reliance), assistive equipment, and sensory cues. Always start with a professional assessment from a physical therapist or adapted physical activity trainer to customize for individual needs, impairments, and risks like spasticity.

The main core rules and guidelines:

Assessment and personalization: Conduct an initial evaluation to identify sensory and mobility limitations. For visual impairments, incorporate audio or tactile feedback (e.g., verbal cues or braille-labelled equipment); for hearing impairments, use visual signals, closed captions, or sign language instructions. Adapt for tactile sensitivities with padded grips. Focus on balancing muscle groups to prevent overuse, especially in shoulders and scapular stabilizers for wheelchair users.

Frequency: Perform strength exercises 2 or more days per week, with at least 48 hours between sessions for recovery. Non-consecutive days help avoid fatigue in upper body muscles heavily used for wheeling.

Intensity: Start low (e.g., bodyweight or light resistance like 1-5 lb weights or low-tension bands) and progress to moderate (where the last reps feel challenging but maintain form). Use perceived exertion scales with adaptations—descriptive audio for visual impairment or visual charts for hearing impairment. Avoid breath-holding (Valsalva manoeuvre) to prevent blood pressure spikes, especially in spinal cord injuries.

Time (Duration/Sets/Reps): Aim for 2-3 sets of 8-15 repetitions per exercise, focusing on controlled movements (2-3 seconds up, 2-3 seconds down). Sessions should last 20-45 minutes, including warm-ups and cool-downs. Build endurance with higher reps before adding weight.

Type of activity: Emphasize seated, upper-body exercises using adaptive equipment like resistance bands, wrap-around weights, cuffs, or tubing for those with grip issues. Include core and available lower-body work. Use assistive tech: audio-guided apps for visually impaired; visual demos or captioned videos for hearing impaired.

Progression and overload: Increase resistance, reps, or sets every 1-2 weeks as strength improves, but monitor for pain. Use motivational tools like apps with voice feedback for accessibility.

Recovery and safety: Include 3-5 minute warm-ups (e.g., arm circles) and cool-downs with stretching to reduce spasticity and prevent sores. Use stabilizing straps for posture, lock wheels, and have a spotter. Monitor for autonomic dysreflexia (e.g., in high spinal injuries) and skin issues. Hydrate, rest adequately, and stop if pain occurs beyond mild fatigue.

Monitoring and support: Track progress with adaptive tools (e.g., talking scales or visual logs). Participate in group classes for social motivation, with inclusive methods like paired guidance. Consult professionals regularly, especially for conditions like cerebral palsy or vision loss.

Examples of adapted activities are described in Table 3.

Activity	Description and rules for strength development	Sensory adaptations
Seated shoulder press	Sit upright, hold weights or bands at shoulder level, press overhead, lower slowly. 2-3 sets of 8-12 reps; progress by adding resistance. Builds deltoids and triceps.	Audio cues for form (visual impairment); visual diagrams or sign language (hearing impairment).
Resistance band chest press	Loop band around wheelchair back, push arms forward from chest, return controlled. 2-3 sets of 10-15 reps; focus on scapular stability. Targets chest and shoulders.	Tactile band grips; verbal countdowns or apps with voice output.
Bicep curls with cuffs	Use wrap-around cuffs or bands, curl arms toward shoulders, lower slowly. 2-3 sets of 8-12 reps; avoid momentum. Strengthens biceps.	Braille-labelled weights; captioned video tutorials.
Seated row	Pull band or machine handles toward chest, squeeze shoulder blades. 2-3 sets of 10 reps; maintain posture with straps if needed. Targets back muscles.	Audio feedback devices; visual timers or mirrors for self-check.
Core twists	Hold weight or ball, twist torso side-to-side slowly. 2-3 sets of 10-15 reps per side; use chair straps for stability. Builds obliques and core.	Descriptive audio guides; sign-interpreted group sessions.
Triceps kickbacks	Bend forward slightly, extend arm back with weight or band. 2-3 sets of 8-12 reps; spotter for balance. Strengthens triceps.	Tactile positioning aids; closed-captioned apps.

1.4.3. Muscular endurance

Muscular endurance is the ability of muscles or muscle groups to sustain repeated contractions over an extended period without fatigue, which is crucial for wheelchair users who rely heavily on upper-body muscles for propulsion, transfers, and daily activities.

For individuals with sensory impairments (e.g., visual, hearing, or tactile), enhancing muscular endurance improves independence, reduces overuse injuries like shoulder strain, and supports overall quality of life, particularly in populations with conditions like spinal cord injury (SCI), multiple sclerosis, or cerebral palsy. Training adaptations can lead to better cardiorespiratory function, reduced pain, and improved functional status, but must address barriers like limited feedback or equipment access [13-15].

These rules are based on the FITT principle (Frequency, Intensity, Time, Type), with emphases on upper-body and core focus, adapted tools, and sensory accommodations. The main core rules and guidelines are:

Assessment and personalization: Start with a thorough evaluation by a physical therapist to gauge baseline endurance, sensory needs, and impairments. For visual impairments, use audio or tactile cues (e.g., verbal descriptions or textured equipment); for hearing impairments, employ visual aids like diagrams or sign language; for tactile issues, opt for smooth, padded tools. Prioritize balancing muscle groups to prevent imbalances, with extra focus on hamstrings and single-leg elements for visually impaired individuals.

Frequency: Train 2–3 non-consecutive days per week to allow recovery and avoid overuse, especially in upper extremities used for wheeling. This aligns with guidelines for wheelchair users to build endurance progressively.

Intensity: Begin at low to moderate levels (e.g., light resistance where reps feel sustainable but challenging by the end) and progress using perceived exertion scales adapted for senses—audio feedback for visual impairment or visual charts for hearing impairment. Aim for efforts that allow conversation but cause mild fatigue.

Time (Duration/Sets/Reps): Perform 2–4 sets of 15–25+ repetitions per exercise, with sessions lasting 20–45 minutes. Include higher reps to target endurance over pure strength, incorporating rests of 30–60 seconds between sets for recovery.

Type of activity: Use seated, low-impact exercises with adaptive equipment like resistance bands, medicine balls, or ergometers. Integrate circuit training or repetitive motions to mimic daily demands. For sensory adaptations, include audio-guided apps or visual timers; combine with aerobic elements for hybrid benefits.

Progression and overload: Gradually increase reps, sets, or resistance every 1–2 weeks as tolerance builds, monitoring for improvements in daily tasks. Use motivational apps with accessible interfaces to track progress.

Recovery and safety: Incorporate 3–5 minute warm-ups (e.g., light arm circles) and cool-downs with stretching to maintain flexibility and reduce spasticity. Ensure 48+ hours recovery between sessions, use wheelchair locks and posture supports, and watch for signs of fatigue or pain. Hydrate and adapt environments for safety, like clear spaces for visual impairments.

Monitoring and support: Use tools like sit-to-stand tests or push-up assessments adapted for wheelchairs to measure progress. Join inclusive group sessions with sensory accommodations for motivation and social benefits.

Few examples of adapted activities to develop muscular endurance are presented in Table 4.

Activity	Description and rules for endurance development	Sensory adaptations
Seated resistance band rows	Pull band handles toward chest repeatedly, squeezing shoulder blades; 3–4 sets of 20–25 reps, slow tempo. Builds back and shoulder endurance.	Audio cues for rhythm (visual impairment); visual timers or mirrors (hearing impairment).
Arm punches or shadow boxing	Perform rapid punches forward or in sequences; 2–3 sets of 30–60 seconds continuous, building to longer durations. Enhances arm and shoulder endurance.	Verbal countdowns or apps with voice (visual); signed instructions or video demos (hearing).
Bicep curls with bands	Curl arms upward repeatedly with light resistance; 3 sets of 20–30 reps, focusing on controlled lowering. Targets biceps and forearms for propulsion endurance.	Tactile grips; descriptive audio guides.
Seated torso twists	Twist upper body side-to-side holding a light weight or ball; 3 sets of 20–25 reps per side. Improves core endurance for stability.	Audio pacing; visual charts for reps.
Wheelchair push-ups or dips	Lift body slightly off seat or dip using armrests; 2–3 sets of 15–25 reps. Builds chest and triceps endurance, adapted for push-up tests.	Partner guidance for positioning (visual); captioned tutorials (hearing).
Respiratory muscle training	Use devices for loaded breathing cycles (e.g., inspiratory trainers); 2 sets of 10–20 reps daily. Enhances respiratory endurance, vital for overall stamina.	Audio feedback devices; visual pressure gauges.

Consistent training over 8–12 weeks can yield significant improvements in endurance, daily function, and health outcomes.

1.4.4. Flexibility

Flexibility refers to the range of motion available at joints and the ability of muscles to stretch, which is essential for maintaining mobility, preventing injuries, improving posture, and enhancing circulation.

For wheelchair users and for those with sensory impairments (e.g., visual, hearing, or tactile), developing flexibility supports independence in daily tasks like transfers and wheeling, while reducing stiffness from prolonged sitting and overuse of upper body muscles. Adaptations are crucial to ensure safe, effective participation, addressing challenges like limited spatial awareness (visual impairment), communication barriers (hearing impairment), or locomotor impairments [16]. Evidence-based guidelines emphasize gentle, seated activities like adapted yoga or tai chi, which can improve well-being and reduce pain. Also, for this fitness component, the rules are structured around the FITT principle (Frequency, Intensity, Time, Type), with sensory and mobility adaptations. The main core rules and guidelines are:

Assessment and personalization: For visual impairments, use tactile feedback (e.g., hand-over-hand guidance) or audio descriptions; for hearing impairments, provide visual cues like diagrams or sign language; for tactile sensitivities, choose smooth fabrics or minimal contact stretches. Focus on upper body and accessible lower body areas to counter wheelchair-related tightness in chest, shoulders, and hips.

Frequency: Perform flexibility exercises 2–7 days per week, ideally as part of a daily routine or after other workouts. Start with 2–3 sessions for beginners to avoid strain, incorporating them into cool-downs.

Intensity: Use gentle, static stretches to a point of mild tension or slight pull, never pain. For sensory impairments, rely on Rating of Perceived Exertion (RPE) scales adapted with verbal (for visual) or visual (for hearing) prompts, rather than pulse monitoring, which may be inaccurate.

Time (Duration): Hold each stretch for 10–30 seconds, repeating 2–4 times per side. Sessions should last 10–20 minutes, with gradual increases. Include 3–5 minute warm-ups (e.g., light arm circles) to prepare muscles.

Type of activity: Emphasize seated, static stretches or low-impact practices like adapted yoga, Pilates, or tai chi. Use props like resistance bands or doorways for support. Incorporate breathing: inhale to prepare, exhale into the stretch.

Progression and overload: Gradually increase hold times, repetitions, or range every 1–2 weeks as flexibility improves. Monitor progress through functional tests like reach distance, adapted with sensory cues.

Recovery and safety: Breathe normally to avoid dizziness; stop if pain occurs. Lock wheelchair wheels, use spotters for balance, and check for pressure sores pre- and post-session. For spinal fusions or rods, get physician clearance. Create a safe environment (e.g., clear space for visual impairments).

Monitoring and support: Use accessible tools like audio-guided apps for visual impairments or closed-captioned videos for hearing impairments. Join inclusive classes for motivation, with partners providing cues. The main activities to develop flexibility are presented below. (Table 5)

Activity	Description and rules for flexibility development	Sensory adaptations
Neck Rotation	Turn head to one side, looking over shoulder; hold 10–30s, repeat 2–3x per side. Improves neck mobility.	Audio instructions or tactile neck guidance (visual); visual diagrams (hearing).
Shoulder rolls	Roll shoulders up, bacr, and do; hold depression 10–30s, repeat 2–4x. Relaxes shoulders.	Verbal pacing (visual); signed demos (hearing).
Triceps stretch	Reach one arm overhead, bend elbow to touch back; gently press with opposite hand, hold 10–30s, switch sides. Targets triceps and shoulders.	Tactile hand placement (visual); captioned videos (hearing).
Trunk rotation	Place hand on opposite thigh, twist torso while looking over shoulder; hold 10–30s, repeat sides. Enhances spinal flexibility.	Audio cues for twist depth (visual); visual timers (hearing).
Chest stretch (Doorway)	Place bent arm in doorway, turn away gently; hold 10–30s, switch arms. Opens chest muscles.	Partner guidance to doorway (visual); descriptive signs (hearing).
Seated Tai Chi or Yoga poses	Perform adapted sequences like seated warrior or cat-cow; flow for 5–10 min, focusing on breath. Builds overall flexibility.	Audio-led sessions (visual); closed-captioned or signed videos (hearing).

Consistent practice over 4–8 weeks can lead to noticeable improvements in range of motion and comfort.

1.4.5. Body composition

Body composition refers to the proportion of fat mass to lean mass (including muscle, bone, and organs) in the body, which influences overall health, mobility, and risk for conditions like obesity, diabetes, and cardiovascular disease.

For wheelchair users and for those with sensory impairments (e.g., visual, hearing, or tactile), optimizing body composition enhances independence, reduces secondary complications like pressure sores or metabolic issues, and improves quality of life, particularly in populations with spinal cord injury (SCI), multiple sclerosis (MS), or cerebral palsy (CP). Adaptive strategies can build lean mass through exercise while managing fat through nutrition and activity but must accommodate mobility limitations and sensory needs to prevent injury or exclusion [17]. In following table (Table 6), we present the main activities designed for the improvement of body composition.

Activity	Description and rules for body composition development	Sensory adaptations
Hand cycling or arm ergometer	Continuous upper-body cycling at moderate intensity; 20–40 min, 3–5x/week to burn calories and build lean mass in arms/shoulders.	Audio pacing apps (visual); visual speed displays (hearing).
Seated resistance band training	Pulls, presses with bands; 2–3 sets of 10–15 reps, 2–3x/week to increase muscle mass and metabolism.	Tactile grips; verbal countdowns.
Adapted water aerobics	Buoyant arm/upper-body movements in pool; 30–45 min, 3x/week for low-impact calorie burn and lean mass preservation.	Flotation aids with tactile handles; auditory signals.
Seated Yoga or Pilates	Core-focused poses/stretches; 15–20 min daily to improve flexibility, support muscle tone, and aid fat management via mindfulness.	Audio-led sessions (visual); captioned videos (hearing).
Wheelchair propulsion intervals	Alternating fast/slow pushes; 20–30 min, 3x/week to elevate heart rate and build upper-body endurance/lean mass.	Tactile markers for paths (visual); visual timers (hearing).
Nutritional integration with exercise	Pair activities with balanced meals (e.g., protein-rich post-workout); track intake to create mild deficit for fat loss while fuelling muscle growth.	Audio food apps (visual); visual portion guides (hearing).

Consistent application over 8–12 weeks, combining exercise and nutrition, can lead to improved body composition, reduced health risks, and enhanced function.

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