Introduction

Physical activity is an integral part of a healthy lifestyle. Commonly recognized benefits of physical activity include increased exercise tolerance, weight control, strengthening of muscles and bones, decreased risk of cardiovascular and metabolic diseases, enhanced mental health and decreased all-cause mortality.1, 2 Although the promotion of physical activity is important for the able-bodied population, it is even more important for individuals with disabilities because of their greater tendency toward sedentary behavior and increased risk of hypokinetic diseases.3 According to the Healthy People 2010 report, only about one-third of individuals with disabilities participate in leisure-time physical activity as compared with over half for the able-bodied population.4

The Physical Activity Guidelines for Adults with Disabilities from the US Department of Health and Human Services recommend that adults with disabilities perform moderate-intensity exercise for at least 150 minutes a week or vigorous-intensity aerobic activity for at least 75 minutes per week. In addition, the guidelines recommend moderate- or high-intensity resistance training of all the major muscle groups on 2 or more days a week.3

Adhering to physical activity guidelines can be difficult for individuals with disability as decreased mobility renders them susceptible to a multitude of physical barriers. Stairs or curbs become physical barriers preventing access to those who are non-ambulatory and reliant on wheelchairs. Non-automated doors hinder entrance to buildings for individuals who lack grip strength because of difficulty in turning door knobs or grasping the door handles. Once entrance is gained, individuals who are reliant on wheelchairs require passageways wide enough to accommodate wheelchairs, including the areas to and around the exercise equipment.

Title III of the Americans with Disabilities Act (ADA) of 1990 not only mandates that all individuals regardless of race, color, national origin, sex and religion have equal access to public facilities but also includes the accommodation of people with disabilities and mandates that they should be provided the opportunity to benefit from equal goods or services.5, 6 Although ADA has helped to decrease the number of barriers to community services, obstacles to accessibility still remain.7 Figoni et al.5 studied fitness centers in the Kansas City metropolitan area and found no facilities to be 100% accessible and compliant with the law.

Because of the immobility resulting from paralysis, individuals with spinal cord injury (SCI), cerebral vascular accident (CVA) and other paralytic conditions require exercise equipment that is adapted to offset disabilities in order to allow full participation in the activity. Although specialized adaptive equipment such as upper-body ergometers, dynamic standers and functional electrical stimulation cycles are found in medical center therapy clinics and rehabilitation centers, access to such equipment is rare in community fitness centers.

The purposes of this study were twofold: first, to assess the level of compliance with the Title III ADA law by fitness centers in the Hattiesburg, MS area, and second, to assess the level of accommodation of wheelchair-reliant individuals beyond the ADA regulations including availability of specialized adaptive exercise equipment and facility staff trained for the special needs of those with paralytic conditions. As of 2010 the population of the state of Mississippi was 2 967 297 with 142 842 in the Hattiesburg metropolitan area—a city within a surrounding 50-mile radius of rural communities and small towns.8 The percentage of individuals with a work-limiting disability between the ages of 18 and 64 years in the US was 8.2% in 2013.9 Thus, we estimate ~243 318 disabled individuals in the state of Mississippi with 11 713 of those in the Hattiesburg, MS metropolitan area.

Materials and Methods

The search for fitness facilities in the Hattiesburg, MS area was conducted using yellowpages.com. Physical therapy centers, as well as facilities specializing in weight loss, dance, martial arts and massage were excluded from the study. Of the remaining 18 public fitness centers, four were found to be out of business and four did not consent to access. Ten facilities provided unfettered consented access.

A compliance/accommodation checklist was adapted from the 74-item ADA compliance checklist used by Figoni et al.5 Several items were added to the checklist to investigate accommodation of wheelchair-reliant individuals beyond the ADA mandated guidelines. These newly inserted items concerned availability of specialized adaptive equipment such as upper-body ergometers and functional electrical stimulation cycles. In addition, items concerning specialized training of staff for the special needs of those with paralytic conditions were inserted. The full adapted checklist included 82 items (Appendix A).

The manager of each facility was first contacted by telephone in order to request a personal audience for a thorough explanation of the study purpose, procedures and consenting process. The second step was an in-person meeting at the fitness facility for completion of the informed consent documents. Once the informed consent process was completed, the researcher used an ADA Accessibility Stick (Access, Lawrence, KS, USA) to check the ADA compliance. Measurements were conducted for parking areas, entrance ramps, exterior door entrances, path of travel throughout the public area, elevators, restrooms and locker rooms, drinking fountains and accessibility to and around the exercise equipment. For information concerning accommodation of wheelchair-reliant individuals beyond the ADA accessibility, the facility managers were questioned about the training of facility staff and available adaptive equipment.

The level of ADA accessibility and wheelchair-user accommodation was determined as a percentage of those facilities included in the study.

Results

ADA accessibility

All participating fitness centers in the Hattiesburg, MS area were found to be partially compliant with ADA regulations; however, no facilities were found to be in complete compliance (Figure 1). The items of greatest compliance were parking, ramps, elevators and water fountains. Eighty percent of the facilities provided sufficient parking as mandated by ADA. Only one facility did not provide marked handicapped parking spaces and one other provided designated parking spaces that did not meet the mandated spatial dimensions. Six of the participating facilities had wheelchair ramps with three of those ramps meeting the ADA specifications. Two of the ramps did not meet the safe-incline requirement of 12 inches of length for every inch of rise. Also, one ramp did not have the required 60-inch landing space at the bottom of the ramp. Four of the ten participating facilities provided elevators with 100% of the elevators meeting ADA standards. Seventy percent of the wall-mounted water fountains met ADA compliance. Nine participating facilities provided water fountains, with two not allowing knee clearance for wheelchair users to get close enough for use. One facility did not provide a water fountain but allowed participants to place water bottles in a refrigerator.

Figure 1
figure 1

Percentage of facilities that complied with the ADA accessibility requirements and accommodation of individuals who are reliant on wheelchairs.

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Only 50% of the entrance doors met ADA compliance. Half of the facilities required the ability to grasp a door handle and manually open the door for entrance. Fifty percent had automated doors that opened without requiring physical labor. Likewise, only 50% of the customer service desks at the participating facilities had a portion of the desk with a maximum height of 36 inches.

The areas of least compliance were accessibility to exercise equipment and restrooms/locker rooms. Six of 10 facilities provided adequate passageway to exercise rooms, but all 10 facilities failed to provide adequate space between and around the various exercise machines and stations making it difficult for wheelchair users to access the equipment. Three facilities provided no access to one or more exercise areas as they were accessible only by stairs. One other facility provided only a narrow passageway (less than 36 inches) to an exercise area that is inadequate for the wheelchair users.

Restrooms and locker rooms were also among the most inaccessible areas with only 20% compliance. The non-compliance typically centered on inadequate toilet stall dimensions and mirror placement being too high for individuals sitting in wheelchairs. Four facilities provided restroom stalls with less space compared with the mandated 60 × 59 inches, four facilities had mirrors mounted with the bottom edge higher than 40 inches from the floor and one sink area did not provide leg clearance for those in wheelchairs. In addition, two facilities did not provide wall-mounted grab bars in restrooms.

Beyond ADA accessibility

Although public facilities are mandated to provide access to facilities equal to the general public, providing specialized exercise equipment and staffing particular to the needs of the individuals who are reliant on a wheelchair are not specifically mandated. Nevertheless, two facilities did provide limited adaptive equipment for wheelchair-reliant individuals in the form of an SCIFIT exercise machine (a combination upper- and lower-body ergometer with a removable seat that allows access for individuals in wheelchairs) and an upper-body ergometer. None of the ten facilities provided specialized equipment that can initiate exercise to paralyzed muscles such as functional electrical stimulation cycles or similar devices. No facilities provided staffing with specialized training concerning paralytic conditions. Thirty percent of the facilities employed individuals with college degrees in exercise science with certifications concerning the safe training of able-bodied individuals, but none had adapted for therapeutic exercise qualifications.

Discussion

After receiving formal skilled rehabilitation services, individuals who are essentially able bodied are able to sustain their rehabilitation progress and pursue wellness activities with a self-administered exercise program at home or at community fitness centers. This practice is important for the overall continuum of care allowing optimization of rehabilitation, maintenance of restored function and promotion of total body wellness.

The results of this study indicate that, regardless of the ADA mandate, access to community fitness centers is substantially limited for individuals who are reliant on wheelchairs. These results concur with a 1993 study by McClain et al.6 concerning wheelchair access to restaurants in several mid-western cities. McClain et al.6 found that only 53% of the participating restaurants provided handicapped parking and only 66% provided the ADA acceptable ramps when needed. In addition, accommodations needed for wheelchair users to be able to participate fully in the ongoing physical activities via the use of specialized adaptive equipment are inadequate. Similar to the study by Figoni et al.5 in 1998, no physical-fitness facilities were found to be 100% ADA compliant with the lowest compliance concerning free passage to and around the exercise equipment and lack of full accessibility to restrooms.

Many of the impediments to passage in and around the exercise equipment result from exercise machines being placed too closely together. At least 36 inches width to, between and around all exercise equipment is needed to allow adequate access by wheelchair users. Access could be improved by simply rearranging exercise equipment allowing adequate room for wheelchair users to maneuver around exercise stations and machines. Other issues involving lack of access to exercise areas because of inaccessible platforms or stairways and inadequate space in restroom stalls provide more permanent structural challenges.

Adaptive equipment such as upper-body ergometers and functional electrical stimulation cycles is available at rehabilitation clinics but they are rare at community fitness centers. Many individuals who are reliant on wheelchair frequently also lack trunk stability; thus, providing exercise equipment that can be accessed from their own wheelchairs eliminates the risk of injury that may occur during transfers. Fitness centers may be hesitant to purchase adaptive equipment fearing lack of use as exercise adherence among those with disabilities has been reported as typically low.4 However, Dolbow et al.10 found that when individuals with SCI were provided access to exercise equipment such as functional electrical stimulation cycles, the participation rate was twice the exercise rate of the general population.

One other important factor concerning the accommodation of individuals who are reliant on wheelchairs is the presence of staff who are trained for the special needs of those with SCI, CVA or other paralytic conditions. None of the facilities that participated in this study provided staffing that met the safety needs of these special populations. Staffing trained for the special needs of those with paralytic conditions is vital as those with SCI and CVA often have altered hemodynamic responses to exercise.11, 12 After SCI, impairment of the autonomic nervous control system may result in abnormal cardiovascular responses to exercise or other stressful events inducing dangerous conditions such as orthostatic or exercise hypotension or autonomic dysreflexia.12, 13, 14, 15

Conclusion

One and a half decades after the first study on accessibility of public fitness facilities in the Kansas City metropolitan area by Figoni et al.5 this current study in the Hattiesburg, MS area found that ADA compliance remains lacking. Although all 10 of the consenting fitness facilities partially met the ADA guidelines, no facilities were 100% compliant. The areas of least compliance were access to and around the exercise equipment and full access to restrooms. Beyond mandated physical accessibility, accommodation of individuals who are reliant on wheelchairs because of SCI, CVA or similar paralytic conditions was also found to be lacking. Only 20% of facilities provided adaptive exercise equipment, and no facilities provided staffing trained for the special needs of this population. It remains important for health-care professionals and other advocacy groups to stress the need for inclusion and accommodation of individuals with disabilities to community fitness facilities allowing wellness needs to be met. Although this study cannot be generalized to fitness facilities nationwide, it does provide an example of non-compliance with ADA mandates and should be used as an encouragement by facilities to investigate their particular accessibility and accommodation levels. There is a need for further study in a variety of geographical regions in the US to be able to estimate ADA accessibility and accommodation of wheelchair-reliant individuals nationally. Likewise, study outside of the US is advocated to project accommodation of individuals who are reliant on wheelchairs internationally.

DATA ARCHIVING

There were no data to deposit.