Stroke is a leading cause of disability world-wide. In the US, nearly 800,000 people experience a stroke annually.1 Although meaningful advancements have been made in medical and rehabilitative care following stroke, issues like chronic functional impairments, depression, and social isolation often persist.

Intensive rehabilitation is often necessary after stroke and focuses on regaining physical, cognitive, and language function, while also attending to changing psychological needs.2 Systematic reviews support high quality, multidisciplinary stroke care is associated with increased survival and independence.3 However, despite positive rehabilitation outcomes, disability persists among most post-acute persons with stroke.4 Community-based providers and informal caregivers often continue the long-term job of rehabilitation and community reintegration to facilitate increased quality of life (QOL). One type of community-based service accessed post-stroke is adaptive recreation. Adaptive recreation describes sports and other recreational activities, such as painting and gardening, designed for individuals with disabilities using assistive devices or modified equipment to address unique needs. Persons with stroke who experience long-term disability may participate in adaptive recreation for physical activity, social engagement, or other reasons.5

Resilience is the successful adaptation to adversity and includes both recovery (how quickly and completely people bounce back) and sustainability (the capacity to maintain a good QOL).6 Sustainability resilience is associated with persistent circumstances and includes the commitment to purposeful engagements in work, family life, and leisure pursuits despite ongoing challenges, making it particularly relevant to adapting to life following stroke. A study investigating resilience in a large sample of adults aging with long-term physical disability suggested that being more resilient is associated with significantly fewer depressive symptoms and better QOL despite high levels of pain and/or fatigue.7 Across three years, being more resilient predicted better social functioning and less depression.8

Although resilience is often described as a personal trait, it is better conceptualized as a dynamic process occurring across different conceptual levels. The human ability to cope with and adjust to challenges is shaped by their context, both within close interpersonal relationships and their community environment, across time. This involves a constant exchange between a person's internal capacities and external resources within their broader interpersonal or social environments, such as access to a supportive relationship and/or community.9 In the current study, we used a biopsychosocial approach to understanding resilience processes experienced through adaptive recreation participation. In the biopsychosocial model (Fig. 1), health is not viewed simply as absence of disease but as presence of wellness.10 Resilience is critical for well-being and may promote more positive health and QOL outcomes after stroke. Importantly, resilience does not result from one single factor; instead, multiple risk and protective factors contribute to or subtract from the overall likelihood of a resilient outcome. Our biopsychosocial approach to understanding resilience focuses on three key elements: physical, psychological, and social resilience. In this model, enhancing one aspect can also positively impact other aspects of resilience.

As shown in Fig. 1, physical factors related to resilience can include health and fitness and the ability to recover from stress and injury. Physical impacts of stroke can include hemiparesis, loss of balance, lack of coordination, spasticity, and deconditioning.11 Physical activity is important for rehabilitation and recovery post-stroke and prevention of subsequent strokes.12 Research also suggests that engagement in physical activity may be effective for improving mood and building social networks.13,14 Yet persons with stroke often do not engage in recommended levels of activity, citing physical (in)ability, fear of falling, shame, fatigue, and amotivation as barriers.15,16

Psychological factors related to resilience encompass positive emotion, optimism, sense of purpose, self-efficacy, and the ability to cope (typically through active, flexible, and/or pragmatic ways). After stroke, apathy or depression, anxiety and uncertainty about the future, and lacking confidence in one's ability to engage in activities are common.17,18 Although both pharmacological and behavioral interventions exist, psychological difficulties remain under-recognized and under-treated19 for a variety of reasons including stigma, the misperception that these are normal responses to stroke, fear of burdening family members, lack of awareness among caregivers and providers, and access to mental health care.

Social environment factors related to resilience involve perceived social support, maintaining social connections, and access to healthcare and community activities. After stroke, particularly after structured rehabilitation services cease, significant strain may emerge as individuals attempt to return to “normal” life.20 There may be social role changes, such as changes in work status, family structure, and social circles. Persons with stroke may experience social isolation resulting from reduced ability to work and lacking access to participate in community and social experiences.

Participation in adaptive recreation may enhance resilience in persons with stroke by building physical fitness, improving mood and self-efficacy, and building social connections and relationships through engaging in valued activities. Adaptive recreation services aim to overcome barriers by providing individualized assessments, instruction, and adaptive equipment to enhance recreation participation for individuals with disabilities. Several studies have documented the positive influence of adaptive recreation on mood, life satisfaction, QOL, and social life.21,22 Further, when compared to individuals with disabilities who are not participating in adaptive recreation, those who participate report significantly higher physical, psychological, and social QOL, and higher overall satisfaction with life.23 However, these studies are largely cross-sectional or retrospective, include a wide variety of condition/disability groups, and have not specifically examined resilience as an outcome.

This prospective pilot study used a mixed methods approach to explore the association between participating in a 16-week community-based adaptive outdoor cycling program and biopsychosocial aspects of resilience in persons with stroke at 8-weeks and 16-weeks. It was hypothesized that participants would show significant improvements on quantitative physical, psychological, and social outcome assessments. Additionally, qualitative data were used to explore and explain potential benefits of adaptive recreation participation observed in quantitative measures.