From Suicide to Resilience: The Role of Adaptive Sports in Mental Rehabilitation After Spinal Injury – A Case Study of an Indian Paralympian

From Suicide to Resilience: The Role of Adaptive Sports in Mental Rehabilitation After Spinal Injury – A Case Study of an Indian Paralympian | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article From Suicide to Resilience: The Role of Adaptive Sports in Mental Rehabilitation After Spinal Injury – A Case Study of an Indian Paralympian Ravinder Kumar, Vikram Singh This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7158841/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Mar, 2026 Read the published version in Sport Sciences for Health → Version 1 posted 9 You are reading this latest preprint version Abstract Background Adaptive sports benefit individuals with disabilities physically and psychosocially, yet evidence on their long-term psychological impact in clinical populations is limited. Objective To assess psychological and functional progression over 36 months in a paraplegic para-archer with a history of major depression, institutionalization, and suicide attempts. Methods An n-of-1 observational study assessed the athlete at baseline, 6, 12, 18, 24, 30, and 36 months using a five-point Likert questionnaire adapted from DASS-21 and MHQoL. Analyses included percentage change, Cohen’s d, and Percentage of Non-Overlapping Data (PND). Results Depression decreased by 98.9% (d > 1.18; PND = 1.00), anxiety by 51.2%, and stress by 27.9%, signaling strong emotional recovery. Self-image, future outlook, and daily functioning improved 100%, and overall well-being rose 77.9% (d = 1.23–1.26). Relationship quality increased 28.6% (d = 1.46), while independence, mood, and physical health each gained ~ 21.5% (d = 0.80). All domains remained stable at 36 months, with minimal affective fluctuations. Each variable achieved PND ≥ 0.80, indicating moderate to high intervention effectiveness. Conclusion Sustained engagement in adaptive sports led to emotional revitalization, psychosocial resilience, and enduring functional improvement in a trauma-affected individual with spinal cord injury, supporting sport-based interventions in comprehensive rehabilitation. Adaptive Sports Spinal Cord Injury Mental Health Rehabilitation Depression and Anxiety Emotional Resilience Para-Archery Case Study Psychosocial Recovery Figures Figure 1 Figure 2 Figure 3 1. Introduction The Paralympic Games have evolved into a global emblem of resilience, inclusion, and the transformative power of sport. Originating from post-World War II rehabilitation initiatives at Stoke Mandeville Hospital under the vision of Sir Ludwig Guttmann, the Paralympics have provided individuals with disabilities a platform not only for athletic excellence but also for social recognition and psychological empowerment [ 1 ]. Within this context, adaptive sports such as para-archery have demonstrated potential not only for physical rehabilitation but also for addressing complex emotional and mental health challenges [ 2 ]. Spinal cord injuries often carry debilitating psychosocial consequences, extending well beyond physical impairment [ 3 ]. A growing body of literature highlights that individuals with spinal injuries frequently endure chronic stress, clinical depression, anxiety, and identity loss, driven by functional dependency, altered social roles, and perceived stigma [ 4 ]. These psychological burdens can escalate into suicidal ideation, especially in the absence of effective coping mechanisms and structured psychosocial support [ 5 ]. Traditional rehabilitation efforts tend to prioritize physical recovery, often neglecting the psychological and emotional dimensions of trauma [ 6 ]. However, emerging research suggests that adaptive sports offer a multidimensional therapeutic benefit, fostering self-efficacy, social connectivity, emotional resilience, and personal mastery [ 7 ]. Despite these promising associations, a lack of in-depth, culturally grounded case studies remains, exploring how and why adaptive sports facilitate psychosocial recovery, particularly in resource-constrained or underrepresented settings, such as rural India [ 8 ]. This study investigates the compelling case of a bronze medallist in the 2024 Summer Paralympics, Paris, France, an Indian para-archer who experienced a devastating spinal injury (paraplegic patients), followed by profound psychological distress, including multiple suicide attempts and prolonged depressive episodes [ 9 ], [ 10 ]. Through his eventual engagement with structured physical therapy and sports training at the Shri Mata Vaishno Devi Sports Complex, he not only regained physical capacity but also exhibited marked improvements in mental health, emotional resilience, and social reintegration. By examining his journey in depth, this case study addresses a critical gap in the rehabilitation literature, providing insight into the psychological mechanisms by which adaptive sports/recreational participation contributes to recovery in the face of severe trauma. Furthermore, it highlights the importance of culturally sensitive and community-based interventions in mental health rehabilitation. The participant's detailed clinical and psychosocial background is presented in Section 3.1 to contextualize the recovery process. The primary objective of this longitudinal case study was to examine how structured participation in adaptive sports, specifically para-archery, contributed to the psychological rehabilitation of an individual suffering from chronic stress, anxiety, and depression. The study aimed to explore how physical engagement fostered mental resilience, identity reconstruction, and a return to personal mastery following traumatic spinal injury. 2. Materials and Methods This study employed an n-of-1 longitudinal design (May 2022–May 2025) to evaluate the psychological and functional recovery of a paraplegic patient participating in adaptive sports rehabilitation. Psychological assessments were conducted at 6-month intervals, with each time point serving as a baseline for the following phase. This repeated-measures framework enabled within-subject analysis of changes in depression, stress, and anxiety, providing clinically relevant insights into the long-term impact of adaptive sports on psychological adaptation and well-being. 2.1. Participants and Procedures Mukesh (pseudonym), a paraplegic W2-class compound open category athlete from the Indian Para-Archery team, with lower limb impairment, was selected through purposive sampling. Data collection occurred in two phases: Phase 1 involved in-depth interviews and retrospective analysis of medical, psychiatric, and rehabilitation records to establish baseline psychological status; Phase 2 included follow-up interviews and contextual assessment of current emotional state, resilience, and social integration. This approach enabled longitudinal tracking of psychological adaptations associated with sustained engagement in adaptive sports. 2.2. Measures and Variables A self-structured questionnaire was developed, drawing conceptual insight from the DASS-21 and MHQoL frameworks. Tailored to the participant’s adaptive sports rehabilitation context, the assessment evaluated eleven domains: depression, anxiety, stress, self-image, independence, mood, relationships, daily activities, physical health, future outlook, and overall well-being. Each item was rated on a 5-point Likert scale (1 = “Never: This is not true for me at all” to 5 = “Always: This is true almost every time”), enabling standardized, repeated self-assessment across timepoints. The instrument demonstrated acceptable internal consistency (Cronbach’s α = 0.73; McDonald’s Ꞷ = 0.75), supporting its reliability for repeated use. 2.3. Risk of Biasness Data triangulation was used to enhance validity by cross-verifying interviews, medical records, and observational notes. This approach reduced subjective bias and improved reliability by integrating multiple sources. Standardized assessments at fixed intervals further minimized measurement bias. However, as with all single-case designs, some recall and observer bias may remain, particularly in retrospective baseline data (see Fig: 1)[ 11 ]. 2.4. Data Analysis Descriptive statistics, percentage change, and Cohen’s d were used to evaluate changes across six timepoint comparisons: Baseline vs 6 months (T1), 6 vs 12 months (T2), 12 vs 18 months (T3), 18 vs 24 months (T4), 24 vs 30 months (T5), and 30 vs 36 months (T6) [ 12 ]. The 6-month follow-up served as the first baseline (T1), with each subsequent follow-up becoming the new baseline for the next interval. Due to the limitations of Cohen’s d in single-case designs, the Percentage of Non-Overlapping Data (PND) was used as the primary clinical indicator [ 13 ]. Interpretation thresholds followed Scruggs and Mastropieri’s criteria: >0.90 (highly effective), 0.70–0.89 (moderately effective), 0.50–0.69 (questionable), and < 0.50 (ineffective). Effect sizes are reported for supplementary context and should be interpreted cautiously [ 14 ], [ 15 ], [ 16 ]. 3. Results This section presents the participants’ psychological and functional progress across six time points. Quantitative findings are based on a self-tailored questionnaire informed by the DASS-21 and MHQoL frameworks. Given the unique nature of this single-case study, items were adapted to ensure contextual relevance to the participant’s lived experience during adaptive sports rehabilitation. The results include a detailed case profile, outcomes from repeated assessments, and supporting qualitative insights from interviews and records. [17], [18]. 3.1. Participant Characteristics The participant, referred to as Mukesh (pseudonym), a 46-year-old paraplegic male athlete from northern India, sustained a traumatic spinal cord injury in a road accident in 2009, resulting in complete lower-limb paralysis (W2 classification). The sudden loss of mobility and independence led to profound psychological distress, including major depressive symptoms, social isolation, and multiple suicide attempts. Despite receiving ongoing medical care and psychiatric intervention, including admission to a mental rehabilitation facility, Arjun’s condition showed minimal improvement and, in some instances, worsened over time. [19]. Following a multidisciplinary recommendation to explore non-clinical therapeutic strategies, the participant was introduced to para-archery at a regional adaptive sports training center in 2017. Engaging in archery provided a structured routine, sense of purpose, and renewed social engagement, which gradually contributed to improvements in psychological stability and self-efficacy [20]. Through consistent participation, the athlete progressed from basic skill acquisition to elite-level performance, eventually qualifying for and competing in multiple national and international para-archery events, including the 2020 Summer Paralympics. In a remarkable continuation of his journey, he secured a Bronze medal at the 2024 Summer Paralympic Games held in Paris , an achievement that not only marked a personal milestone but also served as a symbol of national pride and resilience. These accomplishments signified more than physical and technical advancement; they reflected a profound psychosocial transformation characterized by enhanced emotional resilience, functional independence, and successful reintegration into public life. Additionally, this case highlights the potential of adaptive sports as a psychosocial rehabilitation tool, especially for individuals facing long-term physical disability and psychological trauma. It underscores how structured sport participation can facilitate recovery by promoting identity reconstruction, emotional regulation, and social inclusion (refer to Appendix Data 1. 3.2. Six-Month Follow-Up At six months, the participant showed modest improvements across emotional and functional domains. Depression, anxiety, and stress scores decreased slightly (− 4.76%, − 7.14%, − 12.5%; Cohen’s d = − 1.41), suggesting partial emotional stabilization. Mood, relationship quality, and daily activity scores improved (20%, 42.86%, 14.29%; Cohen’s d = 1.41), indicating enhanced affect, social engagement, and task initiation. Self-image, independence, physical health, and future orientation remained unchanged, reflecting persistent internalized barriers (Fig: 2). Notably, full non-overlap (PND = 1.0) was achieved in relational and daily activity gains, underscoring targeted psychosocial progress through adaptive sport engagement [21], [22], [23] (refer to Table 1, Fig: 3). Table 1 Summary of baseline vs 6-month follow-up data Variable Baseline 6-month follow-up Mean of Pair SD of Pair Corens’d % Change PND Depression 21 20 20.5 0.71 -1.41 -4.76 0.5 Anxiety 28 26 27 1.41 -1.41 -7.14 0.5 Stress 24 21 22.5 2.12 -1.41 -12.5 0.5 Self-Image 5 5 5 0 0 0 0 Independence 9 9 9 0 0 0 0 Mood 5 6 5.5 0.71 1.41 20 0.5 Relationship 7 10 8.5 2.12 1.41 42.86 1 Daily Activities 7 8 7.5 0.71 1.41 14.29 1 Physical Health 7 7 7 0 0 0 0 Future 8 8 8 0 0 0 0 3.3. Twelve-Month Follow-Up At 12 months, the participant demonstrated broader and more sustained improvements (Table 2; Fig: 2). Depression and stress declined further (− 10%, − 4.76%; Cohen’s d = − 1.41), with full non-overlap (PND = 1), indicating continued emotional recovery. Marked gains were seen in mood, self-image, independence, and daily functioning (33.3–57.1%; Cohen’s d = 1.41; PND = 1), reflecting enhanced self-efficacy and functional reintegration. Relationship quality and future orientation improved modestly, while anxiety remained stable. Physical health showed the most significant rise (57.14%), aligning with increased activity levels and confidence (Fig: 3). Overall, these findings suggest cumulative psychosocial and adaptive benefits sustained through ongoing sport engagement (refer to Appendix Data 1) [24], [25], [26]. Table 2 Summary of T1 vs 12-month follow-up data Variable T1 12 Months Follow-up Mean of Pair SD of Pair Cohens d % Change PND Depression 20 18 19 1.41 -1.41 -10 1 Anxiety 26 26 26 0 0 0 0 Stress 21 20 20.5 0.71 -1.41 -4.76 1 Self-Image 5 7 6 1.41 1.41 40 1 Independence 9 10 9.5 0.71 1.41 11.11 1 Mood 6 8 7 1.41 1.41 33.33 1 Relationship 10 12 11 1.41 1.41 20 1 Daily Activities 8 11 9.5 2.12 1.41 37.5 1 Physical Health 7 11 9 2.83 1.41 57.14 1 Future 8 9 8.5 0.71 1.41 12.5 1 Note: T1 refers to the 6-month follow-up post-baseline. 3.4. Eighteen-Month Follow-Up At 18 months, the participant exhibited further clinical improvement across all domains (Table 3; Fig: 2). Depressive, anxiety, and stress scores declined substantially (− 16.67% to − 23.08%; Cohen’s d = − 1.41; PND = 1), indicating continued emotional recovery and effective symptom management. Notable gains were seen in self-image, independence, mood, and daily functioning (20–44.44%; d = 1.41), reflecting progressive psychosocial reintegration and enhanced self-regulatory capacity. Physical health and future orientation improved markedly, suggesting increased vitality and goal-directed thinking. Relationship quality also strengthened (+ 25%), reinforcing the participant’s sustained interpersonal engagement (Fig: 3). These cumulative effects support the enduring therapeutic efficacy of structured adaptive sports participation (refer to Appendix Data 1) [27], [28]. Table 3 Summary of T2 vs 18-month follow-up data Variable T2 18 Months Follow-Up Mean of Pair SD of Pair Cohens d % Change PND Depression 18 15 16.5 2.12 -1.41 -16.67 1 Anxiety 26 20 23 4.24 -1.41 -23.08 1 Stress 20 16 18 2.83 -1.41 -20 1 Self-Image 7 10 8.5 2.12 1.41 42.86 1 Independence 10 12 11 1.41 1.41 20 1 Mood 8 11 9.5 2.12 1.41 37.5 1 Relationship 12 15 13.5 2.12 1.41 25 1 Daily Activities 11 14 12.5 2.12 1.41 27.27 1 Physical Health 11 14 12.5 2.12 1.41 27.27 1 Future 9 13 11 2.83 1.41 44.44 1 Note: T2 refers to the 12-month follow-up post-baseline. 3.5. Twenty-Four-Month Follow-Up At 24 months, the participant exhibited robust and sustained clinical gains across all variables (Table 4; Fig: 2). Depression, anxiety, and stress decreased further (− 6.25% to − 20%; Cohen’s d = − 1.41; PND = 1), reflecting long-term emotional regulation. Improvements were most prominent in mood (+ 63.64%) and independence (+ 50%), with continued gains in self-image, relationships, daily function, and physical health (26.67–40%; d = 1.41). Future orientation advanced markedly (+ 46.15%), indicating stronger goal-directed thinking and optimism (Fig: 3). These findings confirm the cumulative and stabilizing effects of adaptive sports on psychological resilience, functional autonomy, and reintegration over two years (refer to Appendix Data 1) [29], [30]. Table 4 Summary of T3 vs 24-month follow-up data Variable T3 24 Months Follow-Up Mean of Pair SD of Pair Cohens d % Change PND Depression 15 12 13.5 2.12 -1.41 -20 1 Anxiety 20 16 18 2.83 -1.41 -20 1 Stress 16 15 15.5 0.71 -1.41 -6.25 1 Self-Image 10 14 12 2.83 1.41 40 1 Independence 12 18 15 4.24 1.41 50 1 Mood 11 18 14.5 4.95 1.41 63.64 1 Relationship 15 19 17 2.83 1.41 26.67 1 Daily Activities 14 18 16 2.83 1.41 28.57 1 Physical Health 14 18 16 2.83 1.41 28.57 1 Future 13 19 16 4.24 1.41 46.15 1 Note: T3 refers to the 24-month follow-up post-baseline. 3.6. Thirty-Month Follow-Up At 30 months, the participant demonstrated sustained psychological recovery and functional stability across all domains (Table 5; Fig: 2). Depression, anxiety, and stress levels continued to decline significantly (− 25% to − 33.33%; Cohen’s d = − 1.41; PND = 1), reflecting deepened emotional regulation and resilience. Moderate gains persisted in self-image, future orientation, and relational functioning (15.79–35.71%; d = 1.41), indicating maintained psychosocial growth. Functional variables independence, mood, daily activities, and physical health stabilized at higher levels (+ 11.11%), suggesting consistent self-efficacy and quality of life (Fig: 3). Overall, these outcomes affirm the long-term rehabilitative impact of adaptive sports on emotional well-being and social reintegration (refer to Appendix Data 1). Table 5 Summary of T4 vs 30-month follow-up data Variable T4 30 Months Follow-up Mean of Pair SD of Pair Cohens d % Change PND Depression 12 9 10.5 2.12 -1.41 -25 1 Anxiety 16 11 13.5 3.54 -1.41 -31.25 1 Stress 15 10 12.5 3.54 -1.41 -33.33 1 Self-Image 14 19 16.5 3.54 1.41 35.71 1 Independence 18 20 19 1.41 1.41 11.11 1 Mood 18 20 19 1.41 1.41 11.11 1 Relationship 19 22 20.5 2.12 1.41 15.79 1 Daily Activities 18 20 19 1.41 1.41 11.11 1 Physical Health 18 20 19 1.41 1.41 11.11 1 Future 19 22 20.5 2.12 1.41 15.79 1 Note: T4 refers to the 30-month follow-up post-baseline. 3.7. Thirty-Six-Month Follow-Up At 36 months, the participant maintained overall psychosocial and functional stability with mixed trends across domains (Table 6; Fig: 2). Anxiety decreased slightly (− 9.09%), while depression and stress showed minor reversals (+ 11.11% and + 30%, respectively), with PND = 0, suggesting transient emotional fluctuations. Nevertheless, self-image, independence, mood, and daily functioning continued to improve (13.64–26.32%; Cohen’s d = 1.41), indicating ongoing psychosocial growth and sustained adaptive behavior. Future orientation and perceived physical health remained elevated, reflecting persistent motivation and wellness (Fig: 3). Despite minor variability in mood-related indicators, the overall profile supports long-term benefits of adaptive sports on recovery, maintenance, and life quality (refer to Appendix Data 1) [31], [32], [33]. Table 6 Summary of T5 vs 36-month follow-up data Variable T5 36 Months Follow-up Mean of Pair SD of Pair Cohens d % Change PND Depression 9 10 9.5 0.71 1.41 11.11 0 Anxiety 11 10 10.5 0.71 -1.41 -9.09 1 Stress 10 13 11.5 2.12 1.41 30 0 Self-Image 19 24 21.5 3.54 1.41 26.32 1 Independence 20 23 21.5 2.12 1.41 15 1 Mood 20 24 22 2.83 1.41 20 1 Relationship 22 25 23.5 2.12 1.41 13.64 1 Daily Activities 20 23 21.5 2.12 1.41 15 1 Physical Health 20 23 21.5 2.12 1.41 15 1 Future 22 25 23.5 2.12 1.41 13.64 1 Note: T5 refers to the 36-month follow-up post-baseline. 4. Discussion This case study documents a longitudinal trajectory of psychosocial recovery in a paraplegic athlete following a traumatic spinal cord injury and subsequent chronic institutionalization. Initially marked by major depressive symptoms, suicidal ideation, and affective blunting unresponsive to standard psychiatric care, the participant’s condition was clinically characterized by psychological inertia, learned helplessness, and profound identity disintegration. Despite access to pharmacotherapy and inpatient rehabilitation services, these interventions yielded minimal functional gains. The introduction of structured adaptive sport, specifically para-archery, marked a critical therapeutic turning point. Over a 36-month period, this engagement catalyzed improvements across affective, relational, and functional domains, providing clinically relevant insights into the rehabilitative potential of real-world, performance-based interventions in treatment-resistant cases (refer to Appendix Data 1). The participant’s baseline profile, shaped by nearly a decade of institutional care and emotional disengagement, represents a population for whom traditional therapies often prove insufficient. In this context, the observed post-sport initiation trajectory, including progressive declines in depression (− 57.14% over 30 months), anxiety (− 57.69%), and stress (− 58.33%), reflects more than natural remission. Rather, it suggests activation of therapeutic mechanisms specific to the adaptive sport environment. The structure, goal orientation, and public performance elements inherent in elite sport participation likely facilitated re-engagement with previously inaccessible emotional processes. Clinically, this aligns with trauma recovery models that emphasize the importance of affective reconnection and exposure to meaningful stressors in restoring emotional regulation and psychological flexibility. [ 34 ], [ 35 ], [ 36 ], [ 37 ], [ 38 ], [ 39 ], [ 40 ], [ 41 ] (refer to Appendix Data 1). The case also highlights a striking shift in identity reconstruction. Before para-archery involvement, the participant demonstrated signs consistent with psychological depersonalization, such as emotional flatness, detachment from bodily self-perception, and suicidal rumination, a pattern frequently reported in post-traumatic, institutionally embedded individuals. Following consistent engagement in sport, there was a marked shift toward role redefinition: from passive recipient of care to high-functioning athlete. This transformation, underpinned by sustained improvements in self-image (+ 80% from baseline to 36 months) and mood (+ 300%), supports theories of psychosocial resilience that emphasize mastery, autonomy, and agency restoration as central to long-term recovery [ 27 ], [ 29 ], [ 30 ], [ 35 ], [ 36 ], [ 39 ], [ 42 ], [ 43 ] (refer to Appendix Data 1). Importantly, these gains were not limited to internal psychological states. Functional domains such as independence, daily activities, and physical health demonstrated robust upward trends over time (e.g., independence improved by 122%, physical health by 185.7%), reflecting restored motivation and behavioral activation. The observed functional engagement may have been reinforced by the cognitive demands of para-archery focus, routine, and task precision, which mirror components of executive function rehabilitation. Though formal cognitive metrics were not assessed, the participant’s capacity to travel, compete, and perform consistently at international events suggests indirect enhancement of cognitive-behavioral regulation [ 31 ], [ 32 ], [ 33 ], [ 34 ], [ 44 ], [ 45 ], [ 46 ], [ 47 ], [ 48 ] (refer to Appendix Data 1). An unanticipated but clinically meaningful finding emerged in the relational domain. Initially, the participant demonstrated profound interpersonal withdrawal, a pattern often considered entrenched in chronic psychiatric presentations. However, relational functioning improved by 257% over the 36 months. This suggests that the social scaffolding provided by the adaptive sport environment—peer validation, teamwork, exposure to public engagement—may serve as a reparative context for individuals with trauma-related social impairments. Such improvements are consistent with findings from community-based rehabilitation models, which emphasize relational reciprocity and social reengagement as markers of psychological recovery [ 28 ], [ 29 ], [ 32 ], [ 33 ], [ 34 ], [ 35 ], [ 40 ], [ 42 ], [ 43 ], [ 44 ], [ 46 ], [ 47 ], [ 48 ], [ 49 ], [ 50 ], [ 51 ], [ 52 ] (refer to Appendix Data 1). By the 36-month follow-up, however, some variability emerged, particularly in stress and depression scores, which showed minor reversals. These fluctuations are clinically expected in long-term rehabilitation and may reflect transitional challenges related to sustained performance pressure, future uncertainty, or reintegration fatigue. Notably, core functional domains such as independence, physical health, and daily engagement remained stable, suggesting that once behavioral foundations were established, they could withstand temporary mood dysregulation. This observation aligns with longitudinal trauma literature, where affective symptoms may oscillate, but functional capacity can remain resilient once anchored in purpose-driven activity[ 53 ], [ 54 ] (refer to Appendix Data 1). The therapeutic mechanisms observed here reflect more than incidental outcomes. Adaptive sport appears to function as a naturalistic analogue to several established psychotherapeutic modalities. Elements of behavioral activation (structured routine), exposure therapy (competition stress), cognitive restructuring (role mastery), and even trauma-informed care (safe engagement in risk) were organically embedded in the sporting process. Unlike traditional psychotherapy, however, these interventions occurred within a socially meaningful and identity-affirming environment, increasing adherence and internal motivation, critical factors in populations marked by chronic disengagement[ 55 ], [ 56 ], [ 57 ] (refer to Appendix Data 1). Limitations and Future Directions Despite the clinical richness of this case, several limitations must be acknowledged. The single-subject design precludes generalization and causality. Additionally, the absence of formal behavioral, neurocognitive, or third-party assessments limits multidimensional interpretation. Longitudinal self-report data, while valuable, may be influenced by insight fluctuation or social desirability. Future research should incorporate mixed-method approaches, including clinician-rated scales, qualitative interviews, and neuropsychological metrics. Controlled or multiple-baseline designs could better isolate the unique contributions of sport from confounding psychosocial variables. Clinical Implications This case reinforces the need to view adaptive sport not as a recreational adjunct but as a core therapeutic modality within complex rehabilitation pathways. For individuals unresponsive to conventional care, sport may serve as an immersive therapeutic system, providing structure, socialization, and identity reconstruction without the overt clinical framing that often provokes resistance. Clinicians and rehabilitation teams should consider integrated approaches that blend evidence-based psychological care with experiential, embodied practices that resonate with client interests and capacities. Furthermore, as the participant approaches sport career transitions (e.g., post-competition retirement), follow-up planning should include continued role-based engagement, peer mentorship opportunities, and psychosocial support to preserve the functional and emotional gains achieved. These considerations are vital for sustaining progress in a population vulnerable to regression following the loss of externally structured roles. Conclusion This case offers clinically compelling evidence that sustained participation in adaptive sport can function as a transformative rehabilitation strategy for individuals with severe, treatment-resistant psychiatric and functional impairments. The participant’s evolution from an institutionalized, emotionally disengaged individual to an internationally competitive athlete illustrates how sport can catalyze resilience, identity reform, and social reintegration. For clinicians, rehabilitation planners, and policy developers, this underscores the potential of ecologically grounded, meaning-driven interventions in addressing complex rehabilitation needs where traditional approaches have fallen short. Declarations Conflict of Interest: The authors declare that there are no conflicts of interest regarding the publication of this study. No commercial or financial relationships influenced the research process or outcomes. Data Availability: No data are publicly available due to the sensitive nature of the clinical case. Patient Consent: Written informed consent was obtained from the participant for the use of personal, clinical, and psychological information in this case report. All identifying details have been anonymized to protect patient privacy. Funding: This study did not receive any financial support from government bodies, private organizations, or institutional grants. 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Additional Declarations No competing interests reported. Supplementary Files Appendices.docx Cite Share Download PDF Status: Published Journal Publication published 01 Mar, 2026 Read the published version in Sport Sciences for Health → Version 1 posted Editorial decision: Revision requested 17 Nov, 2025 Reviews received at journal 07 Nov, 2025 Reviewers agreed at journal 07 Nov, 2025 Reviews received at journal 23 Oct, 2025 Reviewers agreed at journal 22 Oct, 2025 Reviewers invited by journal 21 Oct, 2025 Editor assigned by journal 18 Jul, 2025 Submission checks completed at journal 18 Jul, 2025 First submitted to journal 18 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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1","display":"","copyAsset":false,"role":"figure","size":39899,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of the triangulation of the experts\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7158841/v1/f175a2da6b6590bd6f10ca7a.png"},{"id":94916746,"identity":"527146e8-17f9-4b6e-aa4f-8b0bc7c5533d","added_by":"auto","created_at":"2025-11-01 11:47:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":172665,"visible":true,"origin":"","legend":"\u003cp\u003eTrajectories of psychological and functional outcomes over 36 months\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7158841/v1/ab0ffe9405721523f819bafa.png"},{"id":94916755,"identity":"0bfa8f24-d6b3-4615-ae46-e719ba9ab01e","added_by":"auto","created_at":"2025-11-01 11:47:25","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":114876,"visible":true,"origin":"","legend":"\u003cp\u003eGraphical representation of the overall Mean and SD across the timepoints\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7158841/v1/7a7e1b6bc03235d6173cb075.png"},{"id":103766144,"identity":"2dc605f3-4aaa-497a-a2be-eaa53d689bb7","added_by":"auto","created_at":"2026-03-02 16:12:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1460963,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7158841/v1/9e844fdf-9573-45d5-8e50-e62918381ac5.pdf"},{"id":94916745,"identity":"e83c83aa-1cf6-492a-af5d-41b7d525cd2d","added_by":"auto","created_at":"2025-11-01 11:47:25","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":19286,"visible":true,"origin":"","legend":"","description":"","filename":"Appendices.docx","url":"https://assets-eu.researchsquare.com/files/rs-7158841/v1/ce0acaddba25f7cd0d0d14f4.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"From Suicide to Resilience: The Role of Adaptive Sports in Mental Rehabilitation After Spinal Injury – A Case Study of an Indian Paralympian","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eThe Paralympic Games have evolved into a global emblem of resilience, inclusion, and the transformative power of sport. Originating from post-World War II rehabilitation initiatives at Stoke Mandeville Hospital under the vision of Sir Ludwig Guttmann, the Paralympics have provided individuals with disabilities a platform not only for athletic excellence but also for social recognition and psychological empowerment [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Within this context, adaptive sports such as para-archery have demonstrated potential not only for physical rehabilitation but also for addressing complex emotional and mental health challenges [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSpinal cord injuries often carry debilitating psychosocial consequences, extending well beyond physical impairment [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. A growing body of literature highlights that individuals with spinal injuries frequently endure chronic stress, clinical depression, anxiety, and identity loss, driven by functional dependency, altered social roles, and perceived stigma [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. These psychological burdens can escalate into suicidal ideation, especially in the absence of effective coping mechanisms and structured psychosocial support [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTraditional rehabilitation efforts tend to prioritize physical recovery, often neglecting the psychological and emotional dimensions of trauma [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, emerging research suggests that adaptive sports offer a multidimensional therapeutic benefit, fostering self-efficacy, social connectivity, emotional resilience, and personal mastery [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Despite these promising associations, a lack of in-depth, culturally grounded case studies remains, exploring how and why adaptive sports facilitate psychosocial recovery, particularly in resource-constrained or underrepresented settings, such as rural India [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study investigates the compelling case of a bronze medallist in the 2024 Summer Paralympics, Paris, France, an Indian para-archer who experienced a devastating spinal injury (paraplegic patients), followed by profound psychological distress, including multiple suicide attempts and prolonged depressive episodes [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Through his eventual engagement with structured physical therapy and sports training at the Shri Mata Vaishno Devi Sports Complex, he not only regained physical capacity but also exhibited marked improvements in mental health, emotional resilience, and social reintegration.\u003c/p\u003e\u003cp\u003eBy examining his journey in depth, this case study addresses a critical gap in the rehabilitation literature, providing insight into the psychological mechanisms by which adaptive sports/recreational participation contributes to recovery in the face of severe trauma. Furthermore, it highlights the importance of culturally sensitive and community-based interventions in mental health rehabilitation. The participant's detailed clinical and psychosocial background is presented in Section 3.1 to contextualize the recovery process.\u003c/p\u003e\u003cp\u003eThe primary objective of this longitudinal case study was to examine how structured participation in adaptive sports, specifically para-archery, contributed to the psychological rehabilitation of an individual suffering from chronic stress, anxiety, and depression. The study aimed to explore how physical engagement fostered mental resilience, identity reconstruction, and a return to personal mastery following traumatic spinal injury.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cp\u003eThis study employed an n-of-1 longitudinal design (May 2022\u0026ndash;May 2025) to evaluate the psychological and functional recovery of a paraplegic patient participating in adaptive sports rehabilitation. Psychological assessments were conducted at 6-month intervals, with each time point serving as a baseline for the following phase. This repeated-measures framework enabled within-subject analysis of changes in depression, stress, and anxiety, providing clinically relevant insights into the long-term impact of adaptive sports on psychological adaptation and well-being.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1. Participants and Procedures\u003c/h2\u003e\u003cp\u003eMukesh (pseudonym), a paraplegic W2-class compound open category athlete from the Indian Para-Archery team, with lower limb impairment, was selected through purposive sampling. Data collection occurred in two phases: Phase 1 involved in-depth interviews and retrospective analysis of medical, psychiatric, and rehabilitation records to establish baseline psychological status; Phase 2 included follow-up interviews and contextual assessment of current emotional state, resilience, and social integration. This approach enabled longitudinal tracking of psychological adaptations associated with sustained engagement in adaptive sports.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2. Measures and Variables\u003c/h2\u003e\u003cp\u003eA self-structured questionnaire was developed, drawing conceptual insight from the DASS-21 and MHQoL frameworks. Tailored to the participant\u0026rsquo;s adaptive sports rehabilitation context, the assessment evaluated eleven domains: depression, anxiety, stress, self-image, independence, mood, relationships, daily activities, physical health, future outlook, and overall well-being. Each item was rated on a 5-point Likert scale (1 = \u0026ldquo;Never: This is not true for me at all\u0026rdquo; to 5 = \u0026ldquo;Always: This is true almost every time\u0026rdquo;), enabling standardized, repeated self-assessment across timepoints. The instrument demonstrated acceptable internal consistency (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.73; McDonald\u0026rsquo;s Ꞷ = 0.75), supporting its reliability for repeated use.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3. Risk of Biasness\u003c/h2\u003e\u003cp\u003eData triangulation was used to enhance validity by cross-verifying interviews, medical records, and observational notes. This approach reduced subjective bias and improved reliability by integrating multiple sources. Standardized assessments at fixed intervals further minimized measurement bias. However, as with all single-case designs, some recall and observer bias may remain, particularly in retrospective baseline data (see Fig: 1)[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4. Data Analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistics, percentage change, and Cohen\u0026rsquo;s \u003cem\u003ed\u003c/em\u003e were used to evaluate changes across six timepoint comparisons: Baseline vs 6 months (T1), 6 vs 12 months (T2), 12 vs 18 months (T3), 18 vs 24 months (T4), 24 vs 30 months (T5), and 30 vs 36 months (T6) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The 6-month follow-up served as the first baseline (T1), with each subsequent follow-up becoming the new baseline for the next interval. Due to the limitations of Cohen\u0026rsquo;s \u003cem\u003ed\u003c/em\u003e in single-case designs, the Percentage of Non-Overlapping Data (PND) was used as the primary clinical indicator [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Interpretation thresholds followed Scruggs and Mastropieri\u0026rsquo;s criteria: \u0026gt;0.90 (highly effective), 0.70\u0026ndash;0.89 (moderately effective), 0.50\u0026ndash;0.69 (questionable), and \u0026lt;\u0026thinsp;0.50 (ineffective). Effect sizes are reported for supplementary context and should be interpreted cautiously [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eThis section presents the participants’ psychological and functional progress across six time points. Quantitative findings are based on a self-tailored questionnaire informed by the DASS-21 and MHQoL frameworks. Given the unique nature of this single-case study, items were adapted to ensure contextual relevance to the participant’s lived experience during adaptive sports rehabilitation. The results include a detailed case profile, outcomes from repeated assessments, and supporting qualitative insights from interviews and records. [17], [18].\u003c/p\u003e\n\u003cdiv id=\"Sec8\"\u003e\n \u003ch2\u003e3.1. Participant Characteristics\u003c/h2\u003e\n \u003cp\u003eThe participant, referred to as \u003cstrong\u003eMukesh\u003c/strong\u003e (pseudonym), a 46-year-old paraplegic male athlete from northern India, sustained a traumatic spinal cord injury in a road accident in 2009, resulting in complete lower-limb paralysis (W2 classification). The sudden loss of mobility and independence led to profound psychological distress, including major depressive symptoms, social isolation, and multiple suicide attempts. Despite receiving ongoing medical care and psychiatric intervention, including admission to a mental rehabilitation facility, Arjun’s condition showed minimal improvement and, in some instances, worsened over time. [19].\u003c/p\u003e\n \u003cp\u003eFollowing a multidisciplinary recommendation to explore non-clinical therapeutic strategies, the participant was introduced to para-archery at a regional adaptive sports training center in 2017. Engaging in archery provided a structured routine, sense of purpose, and renewed social engagement, which gradually contributed to improvements in psychological stability and self-efficacy [20].\u003c/p\u003e\n \u003cp\u003eThrough consistent participation, the athlete progressed from basic skill acquisition to elite-level performance, eventually qualifying for and competing in multiple national and international para-archery events, including the 2020 Summer Paralympics. In a remarkable continuation of his journey, he secured a \u003cstrong\u003eBronze medal at the 2024 Summer Paralympic Games held in Paris\u003c/strong\u003e, an achievement that not only marked a personal milestone but also served as a symbol of national pride and resilience. These accomplishments signified more than physical and technical advancement; they reflected a profound psychosocial transformation characterized by enhanced emotional resilience, functional independence, and successful reintegration into public life. Additionally, this case highlights the potential of adaptive sports as a psychosocial rehabilitation tool, especially for individuals facing long-term physical disability and psychological trauma. It underscores how structured sport participation can facilitate recovery by promoting identity reconstruction, emotional regulation, and social inclusion (refer to Appendix Data 1.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\"\u003e\n \u003ch2\u003e3.2. Six-Month Follow-Up\u003c/h2\u003e\n \u003cp\u003eAt six months, the participant showed modest improvements across emotional and functional domains. Depression, anxiety, and stress scores decreased slightly (− 4.76%, − 7.14%, − 12.5%; Cohen’s d = − 1.41), suggesting partial emotional stabilization. Mood, relationship quality, and daily activity scores improved (20%, 42.86%, 14.29%; Cohen’s d = 1.41), indicating enhanced affect, social engagement, and task initiation. Self-image, independence, physical health, and future orientation remained unchanged, reflecting persistent internalized barriers (Fig: 2). Notably, full non-overlap (PND = 1.0) was achieved in relational and daily activity gains, underscoring targeted psychosocial progress through adaptive sport engagement [21], [22], [23] (refer to Table\u0026nbsp;1, Fig: 3).\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eSummary of baseline vs 6-month follow-up data\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBaseline\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e6-month follow-up\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean of Pair\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSD of Pair\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCorens’d\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e% Change\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePND\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-4.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-7.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf-Image\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndependence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRelationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDaily Activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysical Health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFuture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\"\u003e\n \u003ch2\u003e3.3. Twelve-Month Follow-Up\u003c/h2\u003e\n \u003cp\u003eAt 12 months, the participant demonstrated broader and more sustained improvements (Table\u0026nbsp;2; Fig: 2). Depression and stress declined further (− 10%, − 4.76%; Cohen’s d = − 1.41), with full non-overlap (PND = 1), indicating continued emotional recovery. Marked gains were seen in mood, self-image, independence, and daily functioning (33.3–57.1%; Cohen’s d = 1.41; PND = 1), reflecting enhanced self-efficacy and functional reintegration. Relationship quality and future orientation improved modestly, while anxiety remained stable. Physical health showed the most significant rise (57.14%), aligning with increased activity levels and confidence (Fig: 3). Overall, these findings suggest cumulative psychosocial and adaptive benefits sustained through ongoing sport engagement (refer to Appendix Data 1) [24], [25], [26].\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 2\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eSummary of T1 vs 12-month follow-up data\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eT1\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e12 Months Follow-up\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean of Pair\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSD of Pair\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCohens d\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e% Change\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePND\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-4.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf-Image\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndependence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRelationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDaily Activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysical Health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFuture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e T1 refers to the 6-month follow-up post-baseline.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\"\u003e\n \u003ch2\u003e3.4. Eighteen-Month Follow-Up\u003c/h2\u003e\n \u003cp\u003eAt 18 months, the participant exhibited further clinical improvement across all domains (Table\u0026nbsp;3; Fig: 2). Depressive, anxiety, and stress scores declined substantially (− 16.67% to − 23.08%; Cohen’s d = − 1.41; PND = 1), indicating continued emotional recovery and effective symptom management. Notable gains were seen in self-image, independence, mood, and daily functioning (20–44.44%; d = 1.41), reflecting progressive psychosocial reintegration and enhanced self-regulatory capacity. Physical health and future orientation improved markedly, suggesting increased vitality and goal-directed thinking. Relationship quality also strengthened (+ 25%), reinforcing the participant’s sustained interpersonal engagement (Fig: 3). These cumulative effects support the enduring therapeutic efficacy of structured adaptive sports participation (refer to Appendix Data 1) [27], [28].\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 3\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eSummary of T2 vs 18-month follow-up data\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eT2\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e18 Months Follow-Up\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean of Pair\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSD of Pair\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCohens d\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e% Change\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePND\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-16.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-23.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf-Image\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndependence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRelationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDaily Activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysical Health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFuture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e T2 refers to the 12-month follow-up post-baseline.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\"\u003e\n \u003ch2\u003e3.5. Twenty-Four-Month Follow-Up\u003c/h2\u003e\n \u003cp\u003eAt 24 months, the participant exhibited robust and sustained clinical gains across all variables (Table\u0026nbsp;4; Fig: 2). Depression, anxiety, and stress decreased further (− 6.25% to − 20%; Cohen’s d = − 1.41; PND = 1), reflecting long-term emotional regulation. Improvements were most prominent in mood (+ 63.64%) and independence (+ 50%), with continued gains in self-image, relationships, daily function, and physical health (26.67–40%; d = 1.41). Future orientation advanced markedly (+ 46.15%), indicating stronger goal-directed thinking and optimism (Fig: 3). These findings confirm the cumulative and stabilizing effects of adaptive sports on psychological resilience, functional autonomy, and reintegration over two years (refer to Appendix Data 1) [29], [30].\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 4\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eSummary of T3 vs 24-month follow-up data\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eT3\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e24 Months Follow-Up\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean of Pair\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSD of Pair\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCohens d\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e% Change\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePND\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-6.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf-Image\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndependence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRelationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDaily Activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysical Health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFuture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e T3 refers to the 24-month follow-up post-baseline.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\"\u003e\n \u003ch2\u003e3.6. Thirty-Month Follow-Up\u003c/h2\u003e\n \u003cp\u003eAt 30 months, the participant demonstrated sustained psychological recovery and functional stability across all domains (Table\u0026nbsp;5; Fig: 2). Depression, anxiety, and stress levels continued to decline significantly (− 25% to − 33.33%; Cohen’s d = − 1.41; PND = 1), reflecting deepened emotional regulation and resilience. Moderate gains persisted in self-image, future orientation, and relational functioning (15.79–35.71%; d = 1.41), indicating maintained psychosocial growth. Functional variables independence, mood, daily activities, and physical health stabilized at higher levels (+ 11.11%), suggesting consistent self-efficacy and quality of life (Fig: 3). Overall, these outcomes affirm the long-term rehabilitative impact of adaptive sports on emotional well-being and social reintegration (refer to Appendix Data 1).\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 5\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eSummary of T4 vs 30-month follow-up data\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eT4\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e30 Months Follow-up\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean of Pair\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSD of Pair\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCohens d\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e% Change\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePND\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-31.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-33.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf-Image\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndependence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRelationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDaily Activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysical Health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFuture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e T4 refers to the 30-month follow-up post-baseline.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\"\u003e\n \u003ch2\u003e3.7. Thirty-Six-Month Follow-Up\u003c/h2\u003e\n \u003cp\u003eAt 36 months, the participant maintained overall psychosocial and functional stability with mixed trends across domains (Table\u0026nbsp;6; Fig: 2). Anxiety decreased slightly (− 9.09%), while depression and stress showed minor reversals (+ 11.11% and + 30%, respectively), with PND = 0, suggesting transient emotional fluctuations. Nevertheless, self-image, independence, mood, and daily functioning continued to improve (13.64–26.32%; Cohen’s d = 1.41), indicating ongoing psychosocial growth and sustained adaptive behavior. Future orientation and perceived physical health remained elevated, reflecting persistent motivation and wellness (Fig: 3). Despite minor variability in mood-related indicators, the overall profile supports long-term benefits of adaptive sports on recovery, maintenance, and life quality (refer to Appendix Data 1) [31], [32], [33].\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 6\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eSummary of T5 vs 36-month follow-up data\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eT5\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e36 Months Follow-up\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean of Pair\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSD of Pair\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCohens d\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e% Change\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePND\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-9.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSelf-Image\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndependence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMood\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRelationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDaily Activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePhysical Health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFuture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e T5 refers to the 36-month follow-up post-baseline.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis case study documents a longitudinal trajectory of psychosocial recovery in a paraplegic athlete following a traumatic spinal cord injury and subsequent chronic institutionalization. Initially marked by major depressive symptoms, suicidal ideation, and affective blunting unresponsive to standard psychiatric care, the participant\u0026rsquo;s condition was clinically characterized by psychological inertia, learned helplessness, and profound identity disintegration. Despite access to pharmacotherapy and inpatient rehabilitation services, these interventions yielded minimal functional gains. The introduction of structured adaptive sport, specifically para-archery, marked a critical therapeutic turning point. Over a 36-month period, this engagement catalyzed improvements across affective, relational, and functional domains, providing clinically relevant insights into the rehabilitative potential of real-world, performance-based interventions in treatment-resistant cases (refer to Appendix Data 1).\u003c/p\u003e\u003cp\u003eThe participant\u0026rsquo;s baseline profile, shaped by nearly a decade of institutional care and emotional disengagement, represents a population for whom traditional therapies often prove insufficient. In this context, the observed post-sport initiation trajectory, including progressive declines in depression (\u0026minus;\u0026thinsp;57.14% over 30 months), anxiety (\u0026minus;\u0026thinsp;57.69%), and stress (\u0026minus;\u0026thinsp;58.33%), reflects more than natural remission. Rather, it suggests activation of therapeutic mechanisms specific to the adaptive sport environment. The structure, goal orientation, and public performance elements inherent in elite sport participation likely facilitated re-engagement with previously inaccessible emotional processes. Clinically, this aligns with trauma recovery models that emphasize the importance of affective reconnection and exposure to meaningful stressors in restoring emotional regulation and psychological flexibility. [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] (refer to Appendix Data 1).\u003c/p\u003e\u003cp\u003eThe case also highlights a striking shift in identity reconstruction. Before para-archery involvement, the participant demonstrated signs consistent with psychological depersonalization, such as emotional flatness, detachment from bodily self-perception, and suicidal rumination, a pattern frequently reported in post-traumatic, institutionally embedded individuals. Following consistent engagement in sport, there was a marked shift toward role redefinition: from passive recipient of care to high-functioning athlete. This transformation, underpinned by sustained improvements in self-image (+\u0026thinsp;80% from baseline to 36 months) and mood (+\u0026thinsp;300%), supports theories of psychosocial resilience that emphasize mastery, autonomy, and agency restoration as central to long-term recovery [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] (refer to Appendix Data 1).\u003c/p\u003e\u003cp\u003eImportantly, these gains were not limited to internal psychological states. Functional domains such as independence, daily activities, and physical health demonstrated robust upward trends over time (e.g., independence improved by 122%, physical health by 185.7%), reflecting restored motivation and behavioral activation. The observed functional engagement may have been reinforced by the cognitive demands of para-archery focus, routine, and task precision, which mirror components of executive function rehabilitation. Though formal cognitive metrics were not assessed, the participant\u0026rsquo;s capacity to travel, compete, and perform consistently at international events suggests indirect enhancement of cognitive-behavioral regulation [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] (refer to Appendix Data 1).\u003c/p\u003e\u003cp\u003eAn unanticipated but clinically meaningful finding emerged in the relational domain. Initially, the participant demonstrated profound interpersonal withdrawal, a pattern often considered entrenched in chronic psychiatric presentations. However, relational functioning improved by 257% over the 36 months. This suggests that the social scaffolding provided by the adaptive sport environment\u0026mdash;peer validation, teamwork, exposure to public engagement\u0026mdash;may serve as a reparative context for individuals with trauma-related social impairments. Such improvements are consistent with findings from community-based rehabilitation models, which emphasize relational reciprocity and social reengagement as markers of psychological recovery [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e], [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] (refer to Appendix Data 1).\u003c/p\u003e\u003cp\u003eBy the 36-month follow-up, however, some variability emerged, particularly in stress and depression scores, which showed minor reversals. These fluctuations are clinically expected in long-term rehabilitation and may reflect transitional challenges related to sustained performance pressure, future uncertainty, or reintegration fatigue. Notably, core functional domains such as independence, physical health, and daily engagement remained stable, suggesting that once behavioral foundations were established, they could withstand temporary mood dysregulation. This observation aligns with longitudinal trauma literature, where affective symptoms may oscillate, but functional capacity can remain resilient once anchored in purpose-driven activity[\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e], [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] (refer to Appendix Data 1).\u003c/p\u003e\u003cp\u003eThe therapeutic mechanisms observed here reflect more than incidental outcomes. Adaptive sport appears to function as a naturalistic analogue to several established psychotherapeutic modalities. Elements of behavioral activation (structured routine), exposure therapy (competition stress), cognitive restructuring (role mastery), and even trauma-informed care (safe engagement in risk) were organically embedded in the sporting process. Unlike traditional psychotherapy, however, these interventions occurred within a socially meaningful and identity-affirming environment, increasing adherence and internal motivation, critical factors in populations marked by chronic disengagement[\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e], [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e], [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e] (refer to Appendix Data 1).\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations and Future Directions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDespite the clinical richness of this case, several limitations must be acknowledged. The single-subject design precludes generalization and causality. Additionally, the absence of formal behavioral, neurocognitive, or third-party assessments limits multidimensional interpretation. Longitudinal self-report data, while valuable, may be influenced by insight fluctuation or social desirability. Future research should incorporate mixed-method approaches, including clinician-rated scales, qualitative interviews, and neuropsychological metrics. Controlled or multiple-baseline designs could better isolate the unique contributions of sport from confounding psychosocial variables.\u003c/p\u003e\u003cp\u003e\u003cb\u003eClinical Implications\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis case reinforces the need to view adaptive sport not as a recreational adjunct but as a core therapeutic modality within complex rehabilitation pathways. For individuals unresponsive to conventional care, sport may serve as an immersive therapeutic system, providing structure, socialization, and identity reconstruction without the overt clinical framing that often provokes resistance. Clinicians and rehabilitation teams should consider integrated approaches that blend evidence-based psychological care with experiential, embodied practices that resonate with client interests and capacities.\u003c/p\u003e\u003cp\u003eFurthermore, as the participant approaches sport career transitions (e.g., post-competition retirement), follow-up planning should include continued role-based engagement, peer mentorship opportunities, and psychosocial support to preserve the functional and emotional gains achieved. These considerations are vital for sustaining progress in a population vulnerable to regression following the loss of externally structured roles.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case offers clinically compelling evidence that sustained participation in adaptive sport can function as a transformative rehabilitation strategy for individuals with severe, treatment-resistant psychiatric and functional impairments. The participant\u0026rsquo;s evolution from an institutionalized, emotionally disengaged individual to an internationally competitive athlete illustrates how sport can catalyze resilience, identity reform, and social reintegration. For clinicians, rehabilitation planners, and policy developers, this underscores the potential of ecologically grounded, meaning-driven interventions in addressing complex rehabilitation needs where traditional approaches have fallen short.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u0026nbsp;\u003c/strong\u003eThe authors declare that there are no conflicts of interest regarding the publication of this study. No commercial or financial relationships influenced the research process or outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability:\u0026nbsp;\u003c/strong\u003eNo data are publicly available due to the sensitive nature of the clinical case.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Consent:\u0026nbsp;\u003c/strong\u003eWritten informed consent was obtained from the participant for the use of personal, clinical, and psychological information in this case report. All identifying details have been anonymized to protect patient privacy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This study did not receive any financial support from government bodies, private organizations, or institutional grants. The research was independently conducted as part of ongoing academic and clinical collaboration.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003e\u0026ldquo;The first Paralympic Games | Royal Society.\u0026rdquo; Accessed: Jun. 04, 2025. [Online]. Available: https://royalsociety.org/blog/2024/08/first-paralympic-games/\u003c/li\u003e\n\u003cli\u003eJ. R. Gold and M. M. Gold, \u0026ldquo;Access for all: The rise of the Paralympic Games,\u0026rdquo; \u003cem\u003eJournal of The Royal Society for the Promotion of Health\u003c/em\u003e, vol. 127, no. 3, pp. 133\u0026ndash;141, May 2007, doi: 10.1177/1466424007077348,.\u003c/li\u003e\n\u003cli\u003eM. A. Budd, D. R. Gater, and I. Channell, \u0026ldquo;Psychosocial Consequences of Spinal Cord Injury: A Narrative Review,\u0026rdquo; \u003cem\u003eJ Pers Med\u003c/em\u003e, vol. 12, no. 7, p. 1178, Jul. 2022, doi: 10.3390/JPM12071178.\u003c/li\u003e\n\u003cli\u003eD. R. 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Han, \u0026ldquo;Behavioral Activation and Brain Network Changes in Depression,\u0026rdquo; \u003cem\u003eJournal of Clinical Neurology (Korea)\u003c/em\u003e, vol. 20, no. 4, pp. 362\u0026ndash;377, Jul. 2024, doi: 10.3988/JCN.2024.0148,.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"sport-sciences-for-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ssfh","sideBox":"Learn more about [Sport Sciences for Health](http://link.springer.com/journal/11332)","snPcode":"11332","submissionUrl":"https://submission.nature.com/new-submission/11332/3","title":"Sport Sciences for Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Adaptive Sports, Spinal Cord Injury, Mental Health Rehabilitation, Depression and Anxiety, Emotional Resilience, Para-Archery, Case Study, Psychosocial Recovery","lastPublishedDoi":"10.21203/rs.3.rs-7158841/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7158841/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eAdaptive sports benefit individuals with disabilities physically and psychosocially, yet evidence on their long-term psychological impact in clinical populations is limited.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eTo assess psychological and functional progression over 36 months in a paraplegic para-archer with a history of major depression, institutionalization, and suicide attempts.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eAn n-of-1 observational study assessed the athlete at baseline, 6, 12, 18, 24, 30, and 36 months using a five-point Likert questionnaire adapted from DASS-21 and MHQoL. Analyses included percentage change, Cohen\u0026rsquo;s d, and Percentage of Non-Overlapping Data (PND).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eDepression decreased by 98.9% (d\u0026thinsp;\u0026gt;\u0026thinsp;1.18; PND\u0026thinsp;=\u0026thinsp;1.00), anxiety by 51.2%, and stress by 27.9%, signaling strong emotional recovery. Self-image, future outlook, and daily functioning improved 100%, and overall well-being rose 77.9% (d\u0026thinsp;=\u0026thinsp;1.23\u0026ndash;1.26). Relationship quality increased 28.6% (d\u0026thinsp;=\u0026thinsp;1.46), while independence, mood, and physical health each gained\u0026thinsp;~\u0026thinsp;21.5% (d\u0026thinsp;=\u0026thinsp;0.80). All domains remained stable at 36 months, with minimal affective fluctuations. Each variable achieved PND\u0026thinsp;\u0026ge;\u0026thinsp;0.80, indicating moderate to high intervention effectiveness.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eSustained engagement in adaptive sports led to emotional revitalization, psychosocial resilience, and enduring functional improvement in a trauma-affected individual with spinal cord injury, supporting sport-based interventions in comprehensive rehabilitation.\u003c/p\u003e","manuscriptTitle":"From Suicide to Resilience: The Role of Adaptive Sports in Mental Rehabilitation After Spinal Injury – A Case Study of an Indian Paralympian","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-01 11:47:20","doi":"10.21203/rs.3.rs-7158841/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-17T09:10:38+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-07T08:37:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"36339163375175303712622977340531689130","date":"2025-11-07T08:23:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-23T12:50:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"321570440571940051162410570096763964397","date":"2025-10-22T07:54:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-21T18:06:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-19T01:42:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-19T01:41:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"Sport Sciences for Health","date":"2025-07-18T14:48:17+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"sport-sciences-for-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ssfh","sideBox":"Learn more about [Sport Sciences for Health](http://link.springer.com/journal/11332)","snPcode":"11332","submissionUrl":"https://submission.nature.com/new-submission/11332/3","title":"Sport Sciences for Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"2d7775de-a85b-405d-b3b2-d130c70574ea","owner":[],"postedDate":"November 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-02T16:08:08+00:00","versionOfRecord":{"articleIdentity":"rs-7158841","link":"https://doi.org/10.1007/s11332-026-01688-8","journal":{"identity":"sport-sciences-for-health","isVorOnly":false,"title":"Sport Sciences for Health"},"publishedOn":"2026-03-01 15:57:53","publishedOnDateReadable":"March 1st, 2026"},"versionCreatedAt":"2025-11-01 11:47:20","video":"","vorDoi":"10.1007/s11332-026-01688-8","vorDoiUrl":"https://doi.org/10.1007/s11332-026-01688-8","workflowStages":[]},"version":"v1","identity":"rs-7158841","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7158841","identity":"rs-7158841","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}