Physical and Psychosocial Benefits of Sports Participation Among Children and Adolescents with Chronic Diseases: A Systematic Review

Background This study aims to identify sports interventions for children and adolescents (CaA) with chronic diseases and evaluate their impact on physical, psychological, and social well-being. The findings of this study will contribute to our understanding of the potential benefits of sports interventions for CaA with chronic diseases and inform future interventions to promote their overall health and well-being. Methods A systematic review was conducted in eight databases. This systematic review followed PRISMA guidelines and utilized a comprehensive search strategy to identify studies on sport-based interventions for CaA with chronic diseases. The review included randomized controlled trials and observational studies that focused on physical and psychosocial outcomes. Results We screened 10,123 titles and abstracts, reviewed the full text of 622 records, and included 52 primary studies. A total of 2352 participants were assessed with an average of 45 ± 37 participants per study. Among the included studies involving CaA with chronic diseases with an age range from 3 to 18 years, 30% (n = 15) autism spectrum disorders, 21% (n = 11) cerebral palsy, 19% (n = 10) were attention deficit hyperactivity disorder, and 17% (n = 9) obesity. Other diseases included were cancer (n = 5), asthma (n = 1) and cystic fibrosis (n = 1). Interventions involved various sports and physical activities tailored to each chronic disease. The duration and frequency of interventions varied across studies. Most studies assessed physical outcomes, including motor performance and physical fitness measures. Psychosocial outcomes were also evaluated, focusing on behavioural problems, social competencies, and health-related quality of life. Conclusion Overall, sport-based interventions effectively improved physical and psychosocial outcomes in CaA with chronic diseases. Interventions are generally safe, and participants adhere to the prescribed protocols favorably. Despite that, there is little evidence that interventions are being implemented. Future studies should include interventions tailored to meet the common issues experienced by CaA with chronic conditions, providing a comprehensive understanding of the impact of sports interventions on those affected. Registration The methodology for this review was pre-determined and registered in the PROSPERO database (registration number: CRD42023397172). Supplementary Information The online version contains supplementary material available at 10.1186/s40798-024-00722-8.


Background
Chronic diseases in children and adolescents (CaA) refer to long-term medical conditions requiring ongoing medical care and management.These conditions can affect a child's physical, emotional, and social well-being, lasting for months, years, or even a lifetime [1].Some common examples of chronic illnesses in children include asthma, diabetes, obesity, cystic fibrosis, autoimmune disorders, cancer, and neurological disorders [1].The prevalence of these disorders varies depending on the specific condition and population studied.About 40% of CaA are affected by at least one chronic disease [2] and 25% had two or more chronic conditions [3].While the statistics highlight the prevalence of chronic health conditions among CaA, it is crucial to recognize that these conditions can significantly impact various aspects of their well-being, encompassing physical health, psychological resilience, and overall quality of life [4].Considering the significant impact on a child's well-being, as well as on their family and caregivers, effective management and support for these conditions are essential to optimize outcomes and quality of life for affected children and their families [5].
Regular physical activity is a significant non-pharmacological approach that can contribute to overall well-being and improve the quality of life [6].There is evidence showing that effective strategies aimed at optimizing the benefits of physical activity participation can promote health in CaA with a variety of chronic diseases, including obesity [7], asthma [8], cystic fibrosis [9], cancer [10], autism spectrum disorders [11] or attention deficit hyperactivity disorders [12].However, recent literature show that youth with chronic diseases often do not meet the recommended guidelines and specific considerations in promoting physical activity [13], and while physical activity is considered a cornerstone in the management and treatment of chronic diseases in CaA [14], several studies have identified significant barriers that hinder young individuals with chronic diseases from engaging in these activities [15].Some of these barriers include physical limitations [16,17], fear of exacerbating symptoms [16,17], lack of motivation [16,17], and lack of opportunities or access [16,17].Moreover, CaA with chronic diseases may feel socially isolated or excluded from physical activity and exercise opportunities due to their condition [13,16,17].This situation may result in a diminished sense of social support and a reduced belief in one's ability to engage in physical activities.Individuals facing chronic diseases may require access to secure and suitable facilities, equipment, or programs to bolster their physical activity aspirations.Consequently, recognizing that obstacles may hinder participation in physical activity, it becomes essential to explore alternative options that can, at the very least, partially mitigate these challenges.
Research suggests that involvement in organized sports tends to remain consistent over time, thereby enhancing the likelihood of maintaining high levels of physical activity into adulthood [18].Furthermore, participation in sports fosters increased self-confidence, a heightened sense of belonging, an enhanced quality of life, and facilitates opportunities for social interactions [19].Sport has been shown to improve young people's physical and psychological function [20].In CaA with chronic diseases, participating in sports could alleviate the barriers reported for physical activity participation because sports provide opportunities for social interaction, structured and supervised activities, and a sense of belonging to a team or community [21].Additionally, sports often have clear rules and objectives, which can help individuals overcome the barriers of not knowing what activities to do or how to do them (e.g., by removing uncertainty about what activities to engage in and how to perform them, sports can alleviate the barrier associated with not knowing how to initiate or participate in physical activities) [19,22].Regular sports participation can also improve physical fitness, self-esteem, and mental health, which can further motivate individuals with chronic diseases to continue engaging in physical activity [22].Although there is a well-established understanding that physical activity and sports participation offer significant health benefits for healthy CaA [20,23], the impact of sports engagement on physical fitness and healthrelated outcomes among young people with chronic illnesses needs to be more adequately explored [13].Thus, the focus of this systematic review is to give an overview of (1) which less formal structured physical activities and sports interventions are used in research for CaA with chronic diseases, (2) the impact on physical fitness, physical activity, psychological well-being, social benefits, and overall quality of life of these interventions.Our intention is to establish a clear differentiation between activities that fall under the umbrella of sports or less formal "structured" physical activities and those classified as exercise, which adheres to specific parameters such as frequency, duration, and intensity.With this understanding, our goal is to facilitate the creation of practical applications for engaging in sports participation among various prevalent pediatric chronic diseases.

Methods
The methodology for this review was pre-determined and registered in the PROSPERO database (registration number: CRD42023397172).This study adhered to the guidelines outlined in the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA Statement [24].

Data Sources and Searches
A comprehensive search strategy was developed to identify peer-reviewed journal articles until February 15, 2023.Potentially eligible studies were identified through a systematic search in the following databases: PubMed, MEDLINE, CINAHL, SPORTDiscus, Web of Science, Scopus, PsycINFO and ERIC.This review followed the PICOS framework.The search strategy included the study population, condition and context using terms and keywords derived from preliminary searches and with the assistance of experts in the subject area (see supplementary file 1 for the search strategy).The study population consisted of CaA (< 18 years of age) with chronic diseases (lasting for years or even lifelong), including obesity, asthma, diabetes, haemophilia, cardiovascular diseases (CVD), cancer, cystic fibrosis, epilepsy, developmental disabilities, cerebral palsy, autism spectrum disorders (ASD), attention-deficit/hyperactivity disorder (ADHD) and Post-traumatic diseases.All sport-based interventions were included (intervention).Studies should have either an intervention group with sports and movement-related activities and a control group without targeted sports interventions (e.g., treatment as usual) or only one intervention group (e.g., observational designs); therefore, the primary subset of studies included randomized controlled trials (RCT), but also randomized trials (RT) and observational studies were included.Both physical (e.g., physical fitness, gross motor skills) and psychosocial (e.g., social behaviours, social support, peer relationships, cognitive functions, or health-related quality of life) outcomes were considered.Mental indicators (e.g., self-efficacy, self-esteem, emotional well-being, etc.) were also considered within this group.Limitations on language or publication date were not applied in this study.

Study Selection
Inclusion criteria were controlled studies including a non-intervention group as a comparison and studies using quantitative comparative observational designs performed in CaA < 18 years old diagnosed with a chronic condition.Studies were excluded if: (a) not participating in any sports interventions, physical activity or leisure-time activities related to sport, (b) they did not include one of the aforementioned chronic conditions (there was a need for a confirmed medical diagnosis for study eligibility), (c) participants above 18 years old, (d) case reports, non-longitudinal observational studies, qualitative studies, letters, and systematic or narrative reviews, (e) did not include physical or psychosocial outcomes.
In this systematic review, the term "sport" is defined as organized, competitive activities with established rules and involving physical exertion.Less formal "structured" physical activities encompass a broad spectrum of leisure physical activities that may not fall under traditional competitive sports but still involve planned and intentional movement.These activities may include, but are not limited to, recreational games, dance, fitness classes, and outdoor play.To be eligible for inclusion, studies should present interventions involving sports or physical activities.
A two-phase article selection process was conducted.Firstly, the titles and abstracts of the articles were screened, followed by the inclusion phase, where the full text of all articles meeting the inclusion criteria was reviewed.The screening and inclusion phases were carried out independently by two reviewers (BSC and AJSO) who were blinded to each other's assessments.Any articles that did not meet the eligibility criteria were documented with reasons using an eligibility checklist.Any disagreements between the two reviewers were resolved by a third reviewer (JFG).

Search and Selection Process
The flow chart of the selection process is shown in Fig. 1.We identified 10,123 records from the eight databases.From these, 979 duplicates were removed.After the screening of the titles and abstracts, 8525 were excluded.Two sources were acquired externally; consequently, during the inclusion phase, we thoroughly examined the full text of 621 records, assessing the eligibility of all reports.Finally, we identified 52 studies that met the inclusion criteria .

Data Extraction
For each study included in the review, data were extracted on general characteristics of the study (author, year of publication, setting -intervention location-, sample size (in controlled studies, the number of participants receiving control and intervention); sociodemographic characteristics (sex, age, chronic disease); description of the intervention (sport, duration, frequency, main results, adverse effects, adherence).Physical and psychosocial outcomes and methods of assessment were also retrieved.

Methodological Quality
The PEDro (Physiotherapy Evidence Database) scale was used to assess the methodological quality of the studies.It was developed to provide a standardized method for evaluating the internal validity of clinical trials in physiotherapy.The PEDro scale consists of 11 items, each assessing different aspects of the study design, conduct, and analysis.These items include criteria such as random allocation, concealed allocation, baseline comparability, blinding of subjects, therapists, and assessors, intentionto-treat analysis, and statistical reporting.Item 1, related to external validity, was not included in the overall score calculation.The total PEDro score for a study is the sum of scores across the items (from 0 to 10), with a higher score indicating better methodological quality.

Description of Studies
A summary of the included studies is reported in Table 1.
The studies encompassed a range of designs, sample sizes, and participant characteristics to provide diverse insights into the effects of sport participation on CaA with chronic conditions.All included studies used a longitudinal design; however, 24% did not include a non-intervention comparison group, 18 (34%) were quasi-experiments, and 22 (42%) utilized an RCT design.A total of 2352 participants were assessed, with an average of 45 participants per study (ranging from 6 [71] to 222 [69], per study).The age of the participants ranged on average from (mean ± sd) 4.9 ± 0.6 [32] to 15.0 ± 1.0 [63].The age range was 3 to 18 years.The included studies were categorized based on the type of chronic diseases, considering the following categories: ASD (n = 15), cerebral palsy (n = 11), ADHD (n = 10), obesity (n = 9), cancer (n = 5), asthma (n = 1) and cystic Fibrosis (n = 1).
The systematic review included a diverse range of interventions that interventions took place in various settings and facilities.These included schools, high schools or universities' gymnasiums, summer camps, sports centres, community facilities (e.g., shooting associations), homes (e.g., active video games), golf clubs, community therapy centres, clinical settings (e.g., outpatient clinics), horse centres, campsites, judo facilities, local indoor hydrotherapy and swimming pools, YMCA facilities, basketball pitches, gymnastic halls and local soccer clubs.The duration and frequency of the interventions varied across the studies.Some studies implemented interventions that lasted for one week [69,72,75], while others extended over eight months [26], one year [43] or even one and a half years [54].The prescribed exercise frequency in the selected studies also differed, with some studies offering sessions multiple times per week (e.g., five sessions per week), while others provided interventions on a less frequent basis (e.g., one session per week), with most of the studies offering 2-3 sessions per week [25-35, 39, 41, 44, 45, 47, 53, 55-63, 65-68, 70-72, 74-76].Further details can be found in Table 1.
The psychosocial outcomes were categorized into three distinct groups.The first group, labeled "Behavioral Problems and Social Competencies", focused on examining the interplay between behavioural problems and social competencies.These variables aimed to investigate the relationship between different aspects of behaviour and social functioning, encompassing social skills, social behaviour, and psychological factors.The variables within this group encompassed measures of social behaviours, social skills, and peer relationships, as well as psychological factors such as anxiety, depression, and self-perception.Additionally, specific variables related to ASD and ADHD were included to explore the severity of their behaviours and their impact on social functioning.Social behaviours and skills (behavioural problems and social competencies, or communication skills) were assessed in 13 (25%) studies [25, 26, 30-32, 45, 46, 48, 59, 73-76].Other psychological included factors such as self-image concept and personality [35,53,55,58,61,63,64,66,75] or perceived competence [58,70].Another group of variables focused on Executive Functioning and Attention Abilities.Multiple domains of attention, including selective attention, sustained attention, attentional control, and divided attention.The last group focused on Health-Related Quality of Life (HRQoL), that was assessed in 13 occasions [32,39,40,43,44,52,63,64,66,68,69,71,72].An overview of the tools utilized for the assessment of these outcomes is available in Supplementary File 2.

ASD
The overall methodological quality of the included studies, as assessed by the PEDro scale ranged from 1 to 8 out of 10.Notable studies such as Pan et al. [74] achieved a high score of 8, reflecting excellent methodological quality, while the studies by García-Gómez et al. [25] and López-Diaz et al. [26] received lower scores, suggesting lower methodological quality.
The interventions for individuals with ASD encompassed activities such as horse-riding, soccer, judo, ball games, dances, active video games, swimming, and table tennis [25-29, 31, 32, 37, 48, 59, 70, 73-76].Two of the  The PEDro scale (item 1, pertaining to external validity, is excluded from the total score calculation, which ranges from 0 to 10).HRQoL Health-related quality of life studies also employed active video games [28,70].The interventions varied in terms of activity type, duration, and frequency, reflecting the diversity of approaches to engage this population in physical activities and sport.The duration of interventions ranged from a few weeks to several months.One of the studies spanned one week [75], while most interventions spanned 8-14 weeks with sessions lasting 45-75 min conducted once or twice a week.A more intensive approach involved a 12-week program with 40-min sessions conducted five times a week [32,73].These studies on sports interventions for CaA with ASD explored a range of physical and psychosocial outcomes, providing valuable insights into the potential benefits of such interventions.The evaluation of fitness changes was conducted in three interventions [28,29,32] encompassing assessments of muscle endurance, running speed and agility, balance, bilateral coordination, flexibility, and strength.Non-significant changes in these outcomes were reported across these interventions.Motor skills were evaluated in nine studies [26,28,29,31,32,48,59,70,75], with ball games and sports leading to significantly enhanced motor skills, particularly object-control skills, among the participants [48,59].Conversely, an intervention, which utilized Kinect Sports as its foundation, targeted gross motor skills and perceived competence.Although there were no significant enhancements in actual skills, participants reported improved perceptions of competence [70].Aquatic skill measures and social behavior were evaluated, showing significant social improvements alongside improvements in aquatic skills [74].Similarly, enhancements in swimming skills were examined in another study [27].
Improvements in executive functioning and attention abilities were reported in four studies [28,31,73,76].Significant enhancements in working memory, inhibition, regulation, social communication, and repetitive behavior were observed [73], alongside sustained improvements in motor skill proficiency and executive function for at least 12 weeks [31].Similarly, various aspects including adaptive skills, social skills, leadership, withdrawal, anxiety, depression, behavioral problems, atypicality, aggressiveness, hyperactivity, attention problems, and somatization were assessed, noting significant improvements in aggressiveness, interpersonal relations, and social inclusion [25].Autism-related behaviors and social communication difficulties were also examined, identifying significant enhancements in repetitive behaviors, social interaction, social communication, and emotional response [37].

Cerebral Palsy
The PEDro scale revealed excellent methodological quality in the study conducted by Chiu et al. [34] with a high score of 9. Other examples with a good methodological quality (i.e., score of 8) were found [35].
Intervention periods ranged from 4 weeks to 1 year, with different session frequencies and durations.Among the included studies, the intervention period varied from 4 [39,44] to 12 [33,34] weeks, with sessions lengths of only 25 min [39] to 30 min [41] and frequencies varying from 1 to 5 times per week.Notably, there were longerterm studies such as Feitosa et al. [43], with a duration of 1 year and 156 sessions.
Among the studies assessing physical fitness in CaA with cerebral palsy [33-36, 38, 40, 43], several reported significant improvements in various domains.Significant differences were observed in gross motor skills, walk, and balance [42].Enhancements in physical competence, walking, running, jumping, throwing, and sports participation were also documented [40].Similar improvements were reported in another study, which documented gains in mobility, cardiorespiratory fitness, flexibility, balance, walking speed, and gross motor skills [38].Clinically significant improvements were highlighted in functional mobility, physical activity competence, and strength [36].Similarly, positive impacts were observed on gross motor skills, aerobic capacity, and lower limb strength [35].However, not all studies observed significant changes.For example, six weeks of home-based Wii ™ training plus usual therapy did not improve coordination, strength, or hand function in children 9.5 ± 1.9 years of age [34].Further, eight weeks of a video-game based therapy did not enhance manual dexterity for carrying out everyday tasks in children aged 7.0 ± 1.9 years [41].
In the domain of motor skills assessment, while nonsignificant differences were noted in gross motor skills [42], improvements were highlighted in motor functions of upper limb extremities, including increased quantity of limb movements, following virtual reality intervention [41].Reaction time measures significantly improved in the experimental group, suggesting positive effects on motor skills [39].Additionally, significant gains in mobility and gross motor skills were documented [38], along with positive impacts observed on gross motor skills [35].These authors also reported positive effects in several domains, including self-efficacy, goal achievement, child perceptions of goal performance, and satisfaction.The study found that sports skills training had an effective impact on promoting advanced motor skill gains in CaA with cerebral palsy.
Finally, quality of life (HRQoL) was assessed in four studies [39,40,43,44].Significant improvements were demonstrated in self-identified sports-focused participation and activity level goals, reflecting a positive influence on the perceived HRQoL of the participants [36].Additionally, significant improvements in dimensions related to mobility and physical function were observed [43,44], collectively contributing to a positive biopsychosocial profile and, consequently, improved HRQoL.

ADHD
In terms of methodological quality, Benzing and Schmidt [53] and Kadri et al. [54] each scored 6, indicating good methodological quality.At the lower end, studies such as López-Williams et al. [46] and Hupp and Reitman [51] scored 2, suggesting a lower methodological quality.These findings provide an overview of the diverse methodological rigor observed across studies of attention-deficit/hyperactivity disorder within our review.
The studies examining physical fitness outcomes in individuals with ADHD demonstrate diverse effects of physical activity interventions.Specifically, increased muscular capacity and enhancements in aerobic capacity, flexibility and muscular endurance were reported [45], together with improvements in strength/endurance and running speed [46].These changes were associated with improvements in athletic competence and motor proficiency [47].Additional positive effects on motor performance, static and dynamic balance were observed [50].The studies investigating motor skills outcomes reported improvements in gross [30,45,49,53] and fine motor skills [49] following a comprehensive exercise intervention.
Improved cognitive performance, particularly in selective attention [54] or working memory [50], was observed following the intervention, with enhancements in specific executive functions, such as reaction times in inhibition and switching, as well as general psychopathology and motor abilities [53].Conversely, Månsson et al. [52] found non-significant beneficial effects on inattention, hyperactivity, and impulsivity but reported significant improvements in emotional and behavioral functioning.The studies collectively suggest that exercise interventions may positively impact cognitive and executive functions in individuals with ADHD.

Obesity
The methodological assessment for studies related to obesity in our review reveals overall a moderate methodological quality, while the studies by Walker et al. [55], Griffin et al. [60], and Jette et al. [61] each scored 3, and Korsten-Reck et al. [62] scored 2, suggesting lower methodological quality.Overall, the results indicate diverse methodological rigor across the obesity studies included in our review.
The interventions for individuals with obesity included volleyball, football, and physical education activities such as swimming and balloon volleying [55][56][57][58][60][61][62][63][64].Only nine articles have examined the effects of a sports program on this population.Of these, five have utilized team sports [56,57,61,63,64], two have employed group-based sports activities [55,58], and three have opted for mixed interventions alternating between group sports/team sports or individual sports activities [60,62,63].The programs implemented varied in duration, frequency, and activity type.The interventions' duration ranged from 4 to 24 weeks, although most of them were ≥ 10 weeks and < 24 weeks.
Significant improvements were noted in physical fitness domains such as balance, running speed-agility, change-of-direction speed, as well as cardiorespiratory fitness.Motor skills and lower-limb muscle strength also demonstrated significant enhancements.However, not all outcomes were improved; Cvetković et al. [57] found significant pre-to-post improvements in change-of-direction speed, as well as cardiovascular fitness, but not in in muscular fitness, lower-body power or flexibility.Muscle strength was not improved in the study conducted by Cliff et al. [58].
In the current review, psychosocial outcomes were assessed in 6 studies, overall showing improvements in several indicators of health status (e.g., self-esteem improved) and perceived competence [55,58,64].These interventions yielded positive changes in self-esteem, body image, and overall quality of life.However, it is noteworthy that certain outcomes, such as personality and perceived psychological status, did not exhibit significant changes following the interventions.

Cancer
Only five studies have focused on CaA with cancer [65][66][67][68][69].The methodological evaluation reflected an excellent methodological quality in the study by Li et al. [69], which achieved a high score of 8.A moderate methodological quality was also achieved in other studies [66,67].Nevertheless, despite the low number of studies, all of them were randomized trials and, the average number of participants in the experimental groups across these studies was 57.
Regarding the settings, one study was conducted in the hospital [65], two combining hospital and home [67] or outdoor activities [66].Another study was conducted only in the home [68] and the remaining study organized a 4-day physical activity program for cancer patients, involving four sessions during their stay at the campsite [69].A diverse range of physical activity programs for cancer patients lasting less than 4 weeks were implemented [65,66] Active video games were implemented for 8 weeks, both during hospitalization and at home, in another RCT [67].Additionally, an interactive website was used to promote physical activity in a 24-week intervention, with the frequency being voluntary and the duration not specified [68].
Only two studies assessed fitness in CaA with cancer [66,68] reporting improvements in aerobic capacity, flexibility, balance, upper and lower limb strength and muscle endurance.No differences in motor performance (motor skills) were observed in the Hamari et al. 's study [67] focused on the impact of active video games, specifically Nintendo WiiFit ™ games, on cancer patients.The active video game sessions were conducted five times a week for a duration of 30 min each, totaling 56 sessions over an 8-week period.
Positive results in physical, social, and psychological aspects were achieved combining different sports [65].Exercise capacity, self-esteem, and HRQoL were also improved in another study [65].Two additional studies assessed HRQoL as well [68,69].

Asthma
Only one study examined the effect of sports participation interventions in CaA with asthma, and that study had a low methodological quality (2 out of 10 on the PEDro scale) [71].The study conducted by Westergren et al. [71] was a relatively small-scale investigation involving 6 participants.The intervention consisted of active play sessions, including activities such as ball and team games.The duration of the intervention spanned 6 weeks, with sessions held twice a week, each lasting 60 min.The study aimed to assess the impact of regular active play on individuals with asthma, potentially improving the perception of fitness and overall well-being.

Cystic Fibrosis
For cystic fibrosis, only one study was included [72].Different activities were performed (cycling, swimming, walking, dancing, playing ball, skipping ropes, jumping, upper extremity stretching, exercises involving the trunk and lower extremities in gymnastics) over one week resulting in improvement in physical function.The duration of the intervention spanned one week, with participants engaging in sessions lasting 30 to 45 min, conducted four times a week.

Adverse Events and Adherence to the Interventions
Adverse effects data were available in only nine studies (one in ASD, four in cerebral palsy, one in ADHD, one in obesity, and two in cancer).The majority of the interventions examined showed no observable adverse effects; however, in the field of obesity, a single study [57] reported an injury in one participant, with no additional data provided.Notably, a study by Clutterbuck et al. [40] of CaA with cerebral palsy noted some activity modifications that were tailored to individual participants' capabilities.However, beyond this specific instance, no detrimental outcomes were reported across the interventions reviewed.
Alongside the absence of noticeable adverse effects, information regarding adherence was available in only fourteen studies.These studies consistently reported favorable adherence rates to the investigated interventions.Adherence to interventions in ASD exhibits a varied range of 79-100%, underlining the presence of variability but generally high adherence within the examined sample.Notably, only 4 out of 15 studies provided data on adherence.Contrastingly, in cerebral palsy, adherence data were available from 5 out of 11 studies, with reported levels exceeding 75% [36] or surpassing 90% [35,77].The study conducted by Lai et al. [44] showed fluctuating adherence levels throughout the intervention.In the initial week, there was a notable mean adherence of 90%.However, adherence declined in the second week to 83% (56 out of 68 min), and further reductions were observed in weeks three and four, with adherence rates dropping to 69% (45 out of 65 min) and 43% (40 out of 95 min), respectively.For ADHD, data on adherence were only reported in one study [30].In the context of obesity, adherence to interventions exceeded 75%, as reported by three studies.The lone study on asthma reported a commendable adherence rate of 90% [71].Notably, no adherence data were reported for interventions in cancer or cystic fibrosis.

Discussion
This systematic review aimed to examine the effects of sports interventions on physical and psychosocial outcomes in various populations, including individuals with ADHD, cerebral palsy, ASD, cancer, asthma, cystic fibrosis, and obesity.The review found that sports interventions encompassing a wide range of activities, such as basketball, soccer, swimming, and active video games, yielded positive outcomes in terms of motor performance, physical fitness, social behaviours and skills, psychological factors, executive functioning and attention abilities, and HRQoL.However, the diverse results observed underscore the necessity for personalized approaches in therapeutic interventions.While there are many different approaches yielding varied results, standardization within and across different CaA groups is crucial for better understanding the effects.The review acknowledges the importance of tailoring interventions based on specific conditions, age, abilities, and desired outcomes, emphasizing the need for personalized approaches to optimize effectiveness and address individual needs effectively.
Still, overall, sports interventions showed promising benefits in improving the target populations' physical and psychosocial outcomes.Despite the promising results, youth with chronic diseases often fail to meet the guidelines for healthy physical activity.Only 26% of youth with chronic diseases participate in sports once a week [78].This means they engage in competitive and recreational sports even less frequently than their healthy peers.Various barriers can explain these differences, including both personal (e.g., attitudes from the parents or teachers) and environmental factors (e.g., transportation to an adapted sports facility) [79].

ASD
In patients with ASD active video games offer a multisensory and interactive experience which could improve motivation to participate in physical activities.Compared with sports and active recreation activities [28], exergaming (Kinect) improved motor function in CaA with ASD.However, the authors reported that these interventions might not sufficiently promote correct movement patterns to influence skills in CaA [70].
Important improvements in executive functioning and attention abilities were reported [28,30,31,73,76].Possible explanations for these improvements include the involvement in structured rules and routines, which can help develop cognitive skills (i.e., components of executive functioning) [80].Further, the requirement of concentration and focus can also enhance attention skills [25].Notably, it is essential to emphasize that only two of the five studies reported above [31,76] integrated interventions involving team sports.Nevertheless, it is noteworthy that engagement in team sports can also foster social interaction and cooperation, potentially exerting a positive influence on executive functioning and attention capabilities [73].

Cerebral Palsy
CaA with cerebral palsy, with moderate to severe learning disabilities encounter limited access to physical activity and sports [81]; consequently, the most frequently performed physical or sports activities were based on smart devices, specifically video games [33,39,41,77], as well as video dancing [44].This highlights the growing utilization of technology in promoting physical activity in this population to increase motivation [82].Motivation was identified as a significant factor influencing adolescents' participation in physical activity [83].However, these interventions' physical and psychosocial benefits must be considered with caution as some studies did not report positive results [41,77].
There could be several reasons why video game-based therapy in CaA with cerebral palsy may not improve physical or psychosocial outcomes.Some potential reasons include a lack of specificity, as these interventions may not specifically target the underlying motor impairments and functional limitations associated with cerebral palsy.The games used might not adequately address the specific movement patterns or motor skills that need to be improved [84].Another important reason can be insufficient dosage.The frequency and duration, and intensity of video game-based sessions may not be sufficient to induce meaningful changes in motor abilities.Individual differences can also partly explain the lack of significant differences in some outcomes.
We provided evidence that sports interventions can significantly contribute to better motor function and physical fitness, which is particularly important in youth with a neuromuscular disorder [85].Due to decreased coordination, these children typically required additional time to perform motor tasks compared to their peers without such impairments.Children with cerebral palsy can have diverse presentations and varying levels of motor impairments (i.e., spasticity, dyskinetic or/and ataxic), with abnormalities of coordination and balance [86].Video game-based interventions may only cater to some of the individual needs and abilities, leading to limited effectiveness across the population.Lastly, limited transfer to real-life activities might also be an influencing factor as the movements and coordination required in video games may not directly translate into improved abilities for real-world tasks.
The findings of one study [81] identified four categories of factors that influence participation in physical activity: (1) Musculoskeletal pain and other; (2) Knowledge, exercise skills, and life skills such as problem-solving, decision-making, planning, and organizing; (3) Availability challenges, including lack of transportation, professional guidance, adapted and community-based programs, and enjoyable activities; (4) Social support from professionals and peer support with opportunities for social interaction.Therefore, in contrast with the more severely affected children, those with mild to no learning disabilities utilized physical activity to manage pain and maintain functional abilities.In the current study, multiple types of sports activities were used as individual sports (e.g., golf or swimming) and team sports (e.g., Soccer, netball).These interventions promoted motor skill gains and sports-specific physical competence, improved fitness, mobility, and global function, and favoured enjoyment and HRQoL.Sports can, therefore, play a crucial role in overcoming barriers to physical activity in CaA with cerebral palsy by addressing musculoskeletal pain and other impairments [81].Sports have contributed to the development of knowledge and exercise skills, and by offering enjoyable activities, these activities can enhance the attractiveness and accessibility of physical activity for these CaA.However, some considerations must be highlighted.In this population group professional guidance is needed to cater the adapted sport-based programs to the specific needs of children with cerebral palsy [40]; coaches should tailor the sport interventions to accommodate individual capabilities and ensure a safe and inclusive environment.Further, coaches should align the sport interventions with the child's functional goals.These goals may include improving motor skills, coordination, balance, flexibility, and physical fitness.Finally, coaches should foster positive social interactions among participants and encourage peer support.Providing CaA with cerebral palsy opportunities to collaborate and participate alongside their typically developing peers can enhance their overall experience [87].In the current review, coaches prioritized the safety of the participants.They were aware of the specific risks associated with cerebral palsy and took appropriate precautions to minimize the risk of injury during training and competitions.

ADHD
Individuals diagnosed with ADHD often experience social isolation and rejection due to limited motor skills development, lack of coordination, and diminished attention and executive functioning abilities [45].Sports activities offer unique physical, psychological, and social advantages, distinguishing them from traditional exercise interventions [23,88].Given the characteristics of individuals with ADHD, sports can be viewed as a promising tool with significant potential to address their needs.This perspective is supported by the findings of the nine identified articles on sports programs targeting individuals with ADHD in the current review.These studies reveal improvements in physical fitness, motor skills, and variables related to sports performance [30,[45][46][47][49][50][51][52][53], as well as enhancements in psychosocial variables [30,45,46,[50][51][52][53].However, despite these positive findings, further studies with robust designs and methodologies are needed, with longer durations, as most of the existing research does not exceed three months.Additionally, it is worth noting that there were some inconsistent results in the existing literature, highlighting the importance of more comprehensive investigations into the effects of physical activity/sports interventions in individuals with ADHD.
The articles found exhibit a high degree of heterogeneity regarding the type of sport.This limitation prevents the recommendation of a specific sport for this population.However, many of the identified sports share the common element of teamwork or group participation [30, 45-47, 50, 51].This is important because children with ADHD often have problems with peer relationships and are at increased risk for long-term deficits in social functioning [46].Additionally, some of these studies simultaneously included multiple sports activities in the intervention [45-47, 50, 53].This may be beneficial, as evidence suggests that interventions incorporating multiple activities may have the most significant potential to improve ADHD symptoms [53].The weekly frequency of the sessions also varied substantially across the different studies.Although there appear to be some benefits with only one session per week [49,50,52], this needs to be examined in more detail.Similarly, the duration is also an aspect that needs to be clarified.Nevertheless, it is worth noting that the only RCT among the nine articles reported benefits with just three sessions per week, lasting 30 min each, over a period of 2 months [53].These authors propose exergaming as an alternative to traditional physical activity programs, as children with ADHD often find them less interesting and exhausting, limiting their engagement [89].

Obesity
Despite the many existing studies on physical activity in CaA with obesity [90], the diverse range of sports within this group complicates the formulation of recommendations regarding the most suitable type of sports intervention for treating obesity in this age group.CaA with obesity sometimes experience rejection from their peers due to their lack of physical activity skills [91].Consequently, it is important to offer alternatives based on sports programs or non-competitive games as motivating practices for this population, as these ages are crucial for developing obesity and adherence to physical activity.
Overall, it is noteworthy that the duration of the interventions tends to be relatively short (< 24 weeks).According to a systematic review that studied the duration of interventions for reducing overweight and obesity in CaA, the duration of the studies may not be adequate, as they recommend at least ten months (40 weeks) to avoid rebound effects and, therefore, achieve positive mediumto-long-term results [92].Undoubtedly, the duration of interventions can influence the outcomes, as well as the adherence to them.Therefore, finding a balance will be necessary.

Cancer
Only five studies have focused on CaA with cancer [65][66][67][68][69].The settings where the studies were conducted reflect the unique situation in this population, as CaA with cancer combine long periods in the hospital with treatments at home.Thus, we found one in-hospital study [65], one home-based study [68], and three mixed settings [66,67,69].Due to the characteristics of this condition, where the immune system can be affected, the possibility of offering sports programs through exergames can be an alternative.The findings in this regard are controversial, as one study did not find differences between the intervention and control groups in physical outcomes [67].Similarly, in the study by Howell et al. [68], the intervention was delivered through an interactive website designed to encourage physical activity through rewards.Such alternatives and interventions are supported by the growing body of knowledge that uses gamification and new technologies to promote healthy lifestyles with promising results [93].Given the long hospitalization periods in this population group, establishing in-hospital programs is crucial.

Asthma
Only one article was identified in patients with asthma [71].Significant improvements in lung function, cardiorespiratory fitness and quality of life were reported in this twice weekly (6 weeks) intervention based on the ball and team games.ParticipaPts in the study were involved in different focus groups, and they could express that their daily lives and participation in physical activity were constrained by asthma (e.g., they became rapidly exhausted).Reasons limiting their adherence were also described.On the one hand, the authors highlighted the importance of instructors in creating enjoyable programs, enhancing the children's normality and independence, and on the other, the importance of mutual support between participants, which may let them feel normal and competent.

Cystic Fibrosis
Only one study, involving different physical activities, was identified in cystic fibrosis [72].Despite the improvement in physical function, the short duration of the program (one week) and the control of variables mean caution is required when interpreting the results.The authors believe that these sports activities can potentially improve these patients' quality of life.

Adverse Events and Adherence to the Interventions
While previous literature has reported the absence of adverse effects in sport-related activities for CaA with chronic diseases [94,95], the limited availability of data in our study prevents us from drawing definitive conclusions.The paucity of information emphasizes the need for further research and comprehensive data collection to provide a more comprehensive understanding of potential adverse effects in the context of these interventions.It is important to acknowledge the study of Clutterbuck et al. [40] on children with cerebral palsy, which observed activity modifications accommodating individual capabilities, demonstrating a proactive approach to ensure participant safety.However, lack of available data limits our ability to definitively confirm their safety profile.
Regarding adherence rates, the few studies with available data in the current review are in line with previous evidence reporting positive adherence outcomes in sport-related interventions for CaA with chronic diseases, reporting average adherence rates, regardless of condition (e.g., cancer, cardiovascular disease, and diabetes), of 77% [96].However, it is important to consider the study conducted by Benzing and Schmidt on ADHD [53], which specifically investigated the exergaming condition and reported a relatively high dropout rate.This finding echoes previous literature highlighting the potential challenges in maintaining adherence to certain interventions, particularly in specific populations such as individuals with ADHD.As reported above, active video games (i.e., exergaming) have been shown to be beneficial for CaA in clinical and rehabilitative settings [97].Data from the literature indicate that these interventions may offer an interesting impact on childhood with chronic diseases; nonetheless, there are also potential challenges in maintaining adherence to these interventions.When compared to sport-related activities, active video games often involve solitary gameplay, which may limit social interaction.This is particularly important in the current review, where social support was crucial in maintaining adherence to exercise programs [30,58,76].Without opportunities for social engagement or competition, individuals may feel less motivated to continue with exergaming [53].Similarly, the study by Lai et al. [44] on individuals with cerebral palsy, utilizing video and music as intervention components, reported varying adherence rates throughout the intervention period.While the adherence rates were initially high, they gradually declined over time.This finding is consistent with previous research that has acknowledged the potential fluctuations in adherence levels in long-term interventions.It emphasizes the importance of continuous monitoring and adaptation of intervention strategies to sustain engagement and adherence over extended periods [98].This was also the case of the obesity interventions in the current review [58,63,64], despite the high level of dedication and commitment among individuals undergoing the interventions, it was supported the notion that tailored approaches can effectively promote adherence and positive outcomes in weight management programs [99].
Overall, this review aligns with and builds upon previous literature, emphasizing the limited reporting of adverse effects and the favorable adherence rates observed in a small subset of studies on CaA engagement in sport-related activities among individuals with chronic diseases.They highlight the need for continued research and the development of tailored interventions to ensure participant safety and optimize adherence in this population.In the present systematic review, various factors appear to have influenced the observed outcomes.Methodological quality of the studies, the characteristics of the study population, program duration, frequency, and particularly, the nature of the activities conducted, seem to have played significant roles.While these factors have been individually described for each pathology, some general conclusions can be drawn across all groups.Shorter interventions (< 8 weeks) tend to yield more modest results compared to longer-duration interventions [38,39,51,59,67,71,72].Additionally, interventions based on active video games [33,39,67,70] or other activities with less social interaction [52] tend to exhibit comparatively fewer significant changes than interventions based on traditional sports activities or more recreational pursuits.

Study Limitations
The systematic review has several limitations.Firstly, a wide range of chronic diseases are included in the review, which may introduce heterogeneity in terms of the underlying pathophysiology, treatment approaches, and individual needs.Additionally, the age range of the participants is broad, spanning from early childhood to adolescence, which further adds to the variability in terms of developmental stages and potential differences in intervention outcomes.Moreover, the review encompasses a diverse array of sports and physical activities, making it challenging to draw definitive conclusions regarding the specific benefits of each discipline.Another limitation pertains to using various assessment instruments across studies, which introduces variability in outcome measures and may impact the comparability of results.In addition, it is important to acknowledge that the available literature for this review provided limited information on adverse effects and adherence rates.The scarcity of data in these domains across the selected studies is a notable limitation, and further research with a specific focus on these aspects is warranted to enhance our understanding of comprehensive outcomes in this context.Despite these limitations, the systematic review provides valuable insights into the potential effects of sports interventions in CaA with chronic diseases, serving as a foundation for future research and intervention development.

Conclusion
Sports interventions promote motor skill gains, sportsspecific physical competence, fitness, mobility, global function, enjoyment, and quality of life among CaA with chronic diseases.The reviewed interventions demonstrated a relative safety profile with no reported adverse effects.Adherence rates were generally favourable, with high levels of engagement and commitment observed.Challenges in maintaining adherence were noted in certain interventions, particularly in populations such as individuals with ADHD.Tailoring interventions to individual capabilities, providing professional guidance, and fostering positive social interactions were highlighted as important considerations in maximizing the benefits of sports interventions on physical and psychosocial outcomes in CaA with chronic diseases.Nevertheless, further research is needed to better understand the specific determinants of these interventions, including frequency, duration, or type, and to establish the positive associations between sports participation and the overall well-being of CaA with chronic diseases.These results provide valuable insights for practitioners, coaches, and athletes alike, promoting confidence in implementing these interventions as part of comprehensive training and performance enhancement programs without significant concerns regarding adverse effects.

IncludedFig. 1
Fig. 1 PRISMA flow diagram of literature search and selection process

Table 1 (
continued) ADHD Attention-Deficit/Hyperactivity Disorder, ASD Autism Spectrum Disorder, EG Experimental group, CG Control group, RCT Randomized controlled trial.YMCA Young Men´s Christian Association

Table 2
Physical and psychosocial outcomes, adverse events and adherence to the interventions included in the systematic review