Adapted Exercise and Adapted Sport as Rights of Health Citizenship in Italy: A Legal–Policy Rationale and Framework for Inclusion in the Livelli Essenziali di Assistenza (LEA) and the Role of the Chinesiologo

Abstract

Background: Adapted exercise and adapted sport are proven, low-cost interventions for chronic disease prevention, management, and social inclusion. However, in Italy, neither is explicitly included in the Livelli Essenziali di Assistenza (LEA; nationally guaranteed essential healthcare services), creating unequal access, fragmented governance, and unstable funding. Provision remains largely dependent on regional schemes such as Palestre della Salute and Attività Fisica Adattata (AFA). Methods: We conducted a narrative review integrating evidence from international guidelines, systematic reviews, and key Italian legislative reforms (Legislative Decrees n. 36/2021, 163/2022, 120/2023). We also examined policy frameworks from Germany, Sweden, and Norway to identify transferable components that could support the development of a nationally guaranteed, rights-based system for adapted exercise and adapted sport. Results: Consistent evidence shows that adapted exercise improves functional capacity, quality of life, and clinical outcomes while reducing hospitalizations and healthcare expenditures. Adapted sport further enhances psychosocial well-being, inclusion, and participation among people with disabilities. Based on this evidence, we outline a legal-policy framework for LEA integration that places the chinesiologo at the center of multidisciplinary health teams, defines national standards for assessment, individualized programming, and monitoring, and introduces accreditation mechanisms for facilities and professionals. A blended financing approach is proposed, combining National Health Service (SSN) coverage with income-adjusted co-payments and targeted public–private partnerships. Conclusions: Explicit LEA inclusion of adapted exercise and adapted sport would translate scientific evidence into enforceable rights of health citizenship and ensure uniform national provision, in line with constitutional principles affirmed by the Italian Court. Such reform would strengthen prevention and chronic-disease management and institutionalize the role of the chinesiologo within the SSN through nationally standardized yet regionally adaptable delivery models.

1. Introduction

Regular physical activity is a powerful, low-cost intervention across the life course, lowering all-cause mortality and the risk and burden of noncommunicable diseases, while improving functional capacity, mental health, and quality of life [1,2]. Within this broad evidence base, adapted physical activity and adapted sport extend these benefits to people living with chronic conditions and disabilities, enhancing cardiorespiratory fitness, daily functioning, and psychosocial outcomes when appropriate task, intensity, and environmental accommodations are used [3,4]. These scientific and policy syntheses converge on the same point: exercise is health care, and systems should guarantee equitable access to safe, effective physical-activity services “for all ages and abilities”.

Despite this consensus, Italy’s Livelli essenziali di assistenza (LEA; nationally guaranteed essential healthcare services) do not yet explicitly and uniformly recognize structured exercise and adapted sport as guaranteed services nationwide. The current LEA framework—updated by the 12 January 2017 DPCM—codifies prevention, outpatient, and hospital care, yet the design and delivery of exercise-based pathways remain largely delegated to regional initiatives (e.g., Attività Fisica Adattata (AFA; Italian adapted physical activity program); Palestre della Salute (certified health-promoting gyms)) with variable eligibility, settings, and professional roles [5,6]. National guidance has encouraged promotion of physical activity through the Piano Nazionale della Prevenzione 2020–2025 and State–Regions agreements, but implementation is heterogeneous across regions, producing unequal access to adapted exercise opportunities and coordination standards [7].

This public-health and policy gap persists despite growing recognition that exercise represents a core component of chronic disease prevention and management. Addressing it requires not only scientific evidence but also a coherent regulatory framework capable of ensuring national uniformity, safety, and professional accountability. Within this context, Italy’s sport-reform decrees (Legislative Decrees n. 36/2021 [8], 163/2022 [9], and 120/2023 [10]) are relevant but not the starting point of the argument. These decrees define the professional profiles and competencies of the chinesiologo (Art. 41), including: the chinesiologo di base, the chinesiologo delle attività motorie preventive e adattate, and the chinesiologo sportivo, as well as the manager dello sport. However, because these provisions belong to the domain of sport legislation rather than healthcare, they do not in themselves create a national entitlement to exercise-based services. The 2022 corrective [9] removed the “agonistic” qualifier from Art. 41(1) and introduced Art. 41(8-bis) on supervision of AFA, while the 2023 corrective [10] refined Art. 41(2)(b) to emphasize prevention and psychophysical well-being. These reforms acknowledge the specialized nature of exercise practice but do not resolve the fundamental absence of explicit LEA recognition.

We propose a national policy framework to integrate adapted exercise and adapted sport into the LEA, defining minimum service standards, safety and quality requirements, and the central role of the chinesiologo within multidisciplinary teams. Grounded in international guidance and Italy’s recent legislative reforms, the paper articulates: (a) the clinical and public-health rationale for LEA inclusion; (b) the legal and ethical underpinnings (professional responsibility, equity, privacy, and safety); and (c) a practicable model for nationwide rollout that respects regional implementation while ensuring uniform rights to evidence-based exercise services.

The originality of this review lies in its legal–policy perspective: rather than presenting clinical outcomes alone, it frames adapted exercise and adapted sport as enforceable rights of health citizenship, examines their regulatory basis under Legislative Decrees n. 36/2021, 163/2022, and 120/2023 [8,9,10], and discusses the professional accountability of the chinesiologo. In doing so, the paper positions itself within the field of health law and policy, providing a governance-oriented framework that integrates scientific evidence with constitutional principles, professional regulation, and comparative policy analysis.

To guide the analysis, this review addresses three central problem questions: (i) Why do adapted exercise and adapted sport remain excluded from the LEA despite robust scientific and policy evidence? (ii) Which legal, ethical, and regulatory barriers prevent their national implementation within Italy’s decentralized health system? (iii) How could an integrated LEA framework—centered on the competences of the chinesiologo—standardize service delivery, ensure equity, and align Italy with emerging European models of entitlement-based access to supervised exercise services?

To this end, this review aims to address these questions by: (i) synthesizing the scientific, legal, and policy foundations needed to justify LEA inclusion; (ii) analyzing the regulatory and governance barriers that currently hinder national implementation; and (iii) developing an actionable, legally grounded framework for integrating adapted exercise and adapted sport into the LEA, with clearly defined safety standards, equity safeguards, and a central professional role for the chinesiologo within multidisciplinary teams.

2. Materials and Methods

We conducted a narrative review and legal policy analysis. Evidence sources included international and national guidelines/position statements; randomized controlled trials (RCTs), quasi-experimental, cohort and cross-sectional studies; and systematic reviews/meta-analyses on adapted exercise and adapted sport in oncology, cardiovascular disease, respiratory disease, and neurological/neuromuscular conditions. Scientific literature was identified through structured searches in PubMed/MEDLINE, Scopus, Web of Science, and Google Scholar, covering the period 2000–2025. Key terms included “adapted exercise”, “exercise therapy”, “adapted sport”, “physical activity and chronic disease”, “exercise referral schemes”, “health policy”, and “disability and inclusion”, combined with Boolean operators.

Policy and legal sources comprised Italian legislative decrees (n. 36/2021, 163/2022, 120/2023), the DPCM 12 January 2017 on Livelli essenziali di assistenza (LEA), ministerial and State–Regions documents, and relevant EU instruments. Legislative and policy documents were selected through searches on official repositories (Gazzetta Ufficiale, Normattiva, Ministero della Salute, Conferenza Stato–Regioni) using terms such as “LEA”, “attività fisica”, “AFA”, “sport reform”, and “exercise governance”. Priority was given to primary legislative acts, official guidance, and documents issued by institutional bodies.

We used targeted keyword searches and backward/forward citation tracking in English and Italian, privileging higher-level syntheses where available and RCTs for effectiveness estimates. Inclusion criteria comprised: (a) adolescents or adults with chronic conditions or disability; (b) interventions involving structured exercise or adapted sport; and (c) outcomes including functional capacity, quality of life, symptoms, healthcare use, or participation. Exclusion criteria included case reports, non-institutional gray literature, non-validated opinion pieces, and documents without clear authorship or institutional endorsement.

Given heterogeneity and the policy focus, findings were synthesized narratively rather than meta-analytically; formal risk-of-bias pooling was not performed, but consistency across higher-quality designs is reported where relevant. The methodological approach follows established guidance for narrative reviews in health policy and health law, emphasizing transparency, reproducibility, and integration of multidisciplinary evidence.

3. Scientific Evidence

3.1. Adapted Exercise in Chronic Conditions

3.1.1. Oncology

Across cancer types and treatment phases, structured exercise is safe and yields clinically meaningful improvements in cancer-related fatigue, cardiorespiratory fitness, physical function, and health-related quality of life (HRQoL) [11]. The 2019 ACSM international roundtable recommends ~3 sessions/week of moderate-to-vigorous aerobic training (about 30–40 min) plus resistance training ≥2 days/week, with symptom- and treatment-tailored adjustments; subsequent syntheses confirm HRQoL gains and relief of treatment-related symptoms without excess adverse events [12,13]. Consistent with these syntheses, a systematic review reported significant reductions in cancer-related fatigue with exercise programs [14]; preliminary intervention data from a combined-exercise pilot also showed improvements in psychological and physiological variables in oncology settings [15]; moreover, observational evidence links lower physical activity and reduced handgrip strength with greater fatigue and psychological distress in cancer survivors, underscoring the need for screening and individualized programming [16].

Summary and policy implications. These findings confirm that adapted exercise is a clinically effective, low-risk intervention across cancer stages. Because benefits depend on individualized prescription and qualified supervision, oncology exercise represents a prototypical service that requires standardized national pathways—strengthening the rationale for explicit LEA inclusion of adapted exercise.

3.1.2. Cardiovascular Disease (Coronary Heart Disease, Heart Failure)

For secondary prevention, exercise-based cardiac rehabilitation (CR) reduces cardiovascular mortality and hospitalization and improves health-related quality of life (HRQoL) in coronary heart disease (CHD), with benefits consistent across delivery models, including home-based programs [17,18]. In chronic heart failure, CR increases exercise capacity and HRQoL and lowers hospitalization risk; contemporary meta-analyses confirm benefits across phenotypes [19,20]. Complementing this evidence, randomized trials in adult and older cardiovascular patients showed that a 10-week multicomponent outdoor program improved hemodynamic parameters and physical fitness, and that a multicomponent intervention produced gains in hemodynamics, physical fitness, and HRQoL compared with aerobic training alone [21,22].

Summary and policy implications. The robust evidence base for exercise-based cardiac rehabilitation demonstrates that adapted exercise reduces mortality, hospitalization, and costs. These outcomes directly support the need for guaranteed, nationally harmonized access through LEA inclusion of adapted exercise for cardiovascular prevention and chronic disease management.

3.1.3. Chronic Obstructive Pulmonary Disease (COPD)

Pulmonary rehabilitation (PR), a supervised, multicomponent program that integrates exercise training with education and self-management, has one of the most robust evidence bases in rehabilitation medicine. Across randomized trials and meta-analyses, PR consistently produces clinically meaningful improvements in dyspnea, functional exercise capacity, and health-related quality of life (HRQoL) in COPD. Cochrane syntheses and recent narrative updates converge on sizable functional gains and symptom relief, cementing PR as a core standard of care [23,24].

Summary and policy implications. Pulmonary rehabilitation is one of the strongest evidence-based models of adapted exercise. Its structured, supervised nature illustrates why regional variability is insufficient: national LEA recognition would ensure equitable access to programs that are already considered standard of care in COPD.

3.1.4. Neurologic and Neuromuscular Conditions

In Parkinson’s disease, a 2024 Cochrane review concludes that many types of exercise improve motor function and quality of life, with broadly favorable safety; network analyses to date do not identify a universally superior modality, underscoring the value of individualized, adapted programming [25]. In multiple sclerosis, recent meta-analyses report significant improvements in balance, walking ability/endurance, fatigue, and quality of life, including with tele-exercise adjuncts [26,27]. For spinal cord injury, international SCI-specific exercise guidelines recommend ≥20–30 min of moderate–vigorous aerobic activity plus twice-weekly strengthening, reflecting evidence for fitness and cardiometabolic benefits in this population [28,29].

Summary and policy implications. Across neurologic and neuromuscular conditions, adapted exercise improves mobility, function, fatigue, and quality of life. Because these gains depend on precise adaptation of workload, progression, and safety monitoring, they require qualified professionals and standardized pathways—further justifying LEA inclusion of adapted exercise.

Take-home message. Adapted exercise delivers consistent, patient-important improvements across oncology, cardiovascular, respiratory, and neurologic conditions; tailoring mode and dose to functional status and goals preserves safety and maximizes benefit.

3.2. Adapted Sport: Social Inclusion and Secondary/Tertiary Prevention

Participation in adapted and Para sport is associated with gains in psychosocial well-being, social participation, and health-related quality of life (HRQoL) among people with physical and intellectual disabilities. A 2023 meta-analysis reported positive effects on mental HRQoL in adults with physical disabilities who engage in adapted sport [3]. Reviews of Unified Sports (Special Olympics) describe perceived improvements in belonging, peer relationships, and school climate, with mixed-methods syntheses converging on favorable athlete-reported experiences [30]. Emerging systematic reviews also indicate small-to-moderate improvements in participation, mobility, and quality of life with sport or physically active recreation among people living with disability [31].

From a prevention perspective, adapted/Para sport can act as secondary/tertiary prevention by sustaining physical capacity, countering deconditioning, and slowing disability progression through regular training load and structured social engagement—mechanisms aligned with chronic-disease self-management models (e.g., WHO Global Action Plan on Physical Activity [GAPPA] 2018–2030) [4] and consistent with benefits seen in cardiac and pulmonary rehabilitation. Given heterogeneity in impairments and settings, best practice emphasizes person-centered adaptation (rules, equipment, environment), qualified supervision, and standardized outcome monitoring; under these conditions, benefits are most likely to generalize across contexts.

Summary and policy implications. Unlike adapted exercise, adapted sport primarily supports psychosocial well-being, participation, and disability rights, while also contributing to secondary and tertiary prevention. Its evidence base reinforces the need for LEA recognition of adapted sport as a complementary but distinct service, ensuring equitable access to inclusive sport pathways for people with disabilities.

4. Regulatory Framework

4.1. Legislative Decree 36/2021 and the Recognition of the Chinesiologo

Italy represents a unique case in Europe where exercise and sport science graduates have obtained a formal legal recognition as professionals with defined roles and competencies. Legislative Decree n. 36/2021, part of the broader sport reform, introduced Article 41 (“Il chinesiologo”), which identifies the chinesiologo as the university-trained professional responsible for planning, managing, and evaluating physical activity programs for health, prevention, and sport [8].

This legal framework was subsequently refined by two corrective decrees:

• D. Lgs. 163/2022 removed the phrase “anche di livello agonistico” from Art. 41(1), clarifying that the chinesiologo’s remit extends across all physical-activity settings, not only competitive sport; it also inserted Art. 41(8-bis), assigning the chinesiologo delle attività motorie preventive e adattate (AMPA; laurea magistrale, classe LM-67—Scienze e tecniche delle attività motorie preventive e adattate) supervisory authority over AFA programs and structured individual exercise, while the chinesiologo sportivo (laurea magistrale, classe LM-68—Scienze e tecniche dello sport) continues to cover sport-related activities (including adapted sport for clinically stable patients) in synergy with LM-67 during transition phases [9].
• D. Lgs. 120/2023 further amended Art. 41(2)(b), redefining the chinesiologo di base (laurea triennale, classe L-22—Scienze delle attività motorie e sportive) as the professional responsible for “planning, managing and evaluating physical activities aimed at improving quality of life through exercise, useful for prevention, maintenance, and psychophysical well-being” [10].

Although Article 41 does not explicitly name “adapted sport” within the chinesiologo sportivo scope, it does not exclude it. When sport is practiced by persons with disabilities in competitive, federation, or paralympic settings, it falls under “sport” as regulated by the decree; accordingly, the chinesiologo sportivo may operate in adapted sport for clinically stable participants, handling athletic preparation and load progression, in synergy with the chinesiologo AMPA during transition phases from adapted exercise to adapted sports.

Article 42 of the same decree complements this recognition by stipulating that courses in gyms, centers, and sports facilities must be coordinated by a chinesiologo. In practice, the two articles create a dual framework: (a) recognition of the professional profile, and (b) mandatory coordination/supervision of organized physical activity and structured exercise to ensure safety and quality. Within this framework, health-related structured exercise for people with chronic conditions, e.g., AFA (Attività Fisica Adattata) and EFS (Esercizio Fisico Strutturato, i.e., structured exercise pathways used by several regions, including formats such as yoga or tai chi when delivered as exercise programs), is coordinated and programmed by the chinesiologo (LM-67/LM-68 as appropriate) and is not delegated to non-graduate personnel. Only where expressly established by law and accreditation frameworks may other professionals, such as qualified sports instructors holding federation certifications recognized by the Italian National Olympic Committee (CONI) or the Italian Paralympic Committee (CIP), lead sport-specific sessions for clinically stable participants, under the technical protocols and overall coordination of the chinesiologo. This does not, however, equate the academic training of the chinesiologo (LM-67/LM-68) with short-course or federation certificates, which are confined to the sport domain and do not authorize the programming of structured exercise for prevention, rehabilitation, or chronic conditions. Program design, progression, and monitoring are led by the chinesiologo; physicians provide diagnosis, clinical indications, and clinical clearance in higher-risk cases (e.g., unstable conditions or new significant symptoms). This division of labor preserves medical and physiotherapy responsibilities within rehabilitation and assigns the chinesiologo responsibility for adapted exercise and sport programming beyond rehabilitation.

4.2. Regional Frameworks: The Case of Palestre Della Salute

In the absence of LEA inclusion, several Italian regions have independently legislated the provision of structured exercise programs within health systems. The most widespread initiative is that of the Palestre della Salute, first implemented in Veneto and subsequently adopted, with regional adaptations, in Emilia-Romagna, Toscana, Lombardia, Puglia, Piemonte, Umbria, Liguria, Sicilia and Friuli-Venezia Giulia [32,33,34,35,36,37,38,39,40,41].

As of September 2025, Veneto, Emilia-Romagna, and Umbria operate certified networks/registries; Toscana has recently legislated dedicated provisions and is completing implementation; Piemonte has adopted the regional law and is rolling out implementing acts; Lombardia reports ATS-led initiatives but lacks a single regional register; Puglia has legislated and, with a recent regional resolution, has launched a pilot CRAFA (Certificazione Regionale AFA) scheme for the regional certification of adapted physical activity centers, but the full accreditation/registry system remains in an early implementation phase; Liguria and Sicilia have newly enacted laws with implementing measures underway; and Friuli-Venezia Giulia has just established the regional network and is in initial rollout.

These programs typically certify fitness centers or community facilities as providers of exercise for people with chronic diseases, under the supervision of qualified chinesiologi (adapted exercise/sport design, dosing/progression, and monitoring), while physiotherapists intervene within rehabilitation pathways when physiotherapy, including therapeutic exercise, is clinically indicated, and in coordination with local health authorities.

Beyond the Palestre della Salute model, Tuscany pioneered a parallel pathway, AFA, since the early 2000s, offering community-based, low-cost group exercise for older adults and people with stable chronic conditions [42]. Whereas the Palestre della Salute primarily certifies facilities and organizational standards, AFA is delivered as a health-system–linked community service, often coordinated with local health authorities. Local experience points to gains in function and quality of life, yet programs remain heterogeneous in eligibility, funding, referral pathways, and professional standards.

4.3. Critical Issues: Lack of National Standardization

The main regulatory challenge lies in the absence of national standardization. Despite the legal recognition of the chinesiologo through Legislative Decree n. 36/2021 as amended, the integration of exercise into the health system is still delegated to regional laws and policies [8]. This has produced the following:

• Inequalities in access: patients in regions with Palestre della Salute or AFA programs benefit from structured, subsidized exercise, while those in other regions lack comparable services.
• Variability in professional roles: in some regions, chinesiologi are central to program design and delivery, while in others, physiotherapists or sports instructors assume overlapping roles, creating ambiguity.
• Unstable funding mechanisms: without LEA recognition, exercise programs are vulnerable to budget cuts and lack long-term sustainability.
• Weak integration with national policy: while the Piano Nazionale della Prevenzione 2020–2025 encourages physical activity promotion, it provides no binding framework for its translation into guaranteed services [7].

In sum, Italy’s regulatory context has recognized the chinesiologo as a professional figure with defined competencies, but without national LEA inclusion, exercise and adapted sport remain fragmented, regionally dependent services rather than universally guaranteed rights.

5. Legal and Ethical Profiles

5.1. Adapted Exercise and Adapted Sport as a Right of Health Citizenship

In modern welfare states, health is framed not only as access to medical treatment but as an entitlement to preventive and health-promoting services. In the Italian Constitution, Article 32 [43] protects health as a “fundamental right of the individual and an interest of the community,” while Article 117(2)(m) [44] assigns to the State the definition of Livelli essenziali delle prestazioni (LEP), the nationally guaranteed minimum set of benefits concerning civil and social rights. In healthcare, the LEP take the form of the Livelli essenziali di assistenza (LEA), specified by the DPCM 12 January 2017 [5]. Since 2023, Article 33 [45] also recognizes the educational, social, and psychophysical well-being value of sport “in all its forms.” Read together—and in light of the Constitutional Court judgment n. 282/2002 [46], which establishes that the State must guarantee uniform and non-derogable essential levels of social rights throughout the national territory—these provisions support the view that adapted exercise and adapted sport can be framed as rights of health citizenship once explicitly included among nationally guaranteed essential services.

From a bioethical perspective, the WHO Global Action Plan on Physical Activity 2018–2030 frames physical activity as a global public good, emphasizing equity of access and governments’ duty to create enabling environments [4]. Applying this to Italy, the legal recognition of the chinesiologo (D. Lgs. 36/2021 [8], as amended) strengthens the normative foundation: the State now acknowledges that exercise requires professional expertise and therefore can be considered a service warranting uniform provision under the LEA. Until LEA inclusion occurs, however, access to adapted exercise and adapted sport remains heterogeneous, undermining the constitutional principle of equity.

5.2. Professional Responsibility of the Chinesiologo

The recognition of the chinesiologo carries with it not only rights but also professional responsibilities. Under the Italian system, liability can be civil, criminal, or disciplinary. With the Legge Gelli-Bianco (Law n. 24/2017) [47], the healthcare framework introduced specific rules on patient safety and professional responsibility, extending obligations of diligence, prudence, and technical adequacy to all health-related operators.

Although the chinesiologo is not (yet) a health professional in the narrow legal sense, the application of exercise in chronic disease management, rehabilitation, and adapted sport situates their practice within the sphere of health services. This raises three implications: (1) Duty of competence, ensuring evidence-based programming, adherence to international guidelines, and continuous professional updating; (2) Duty of safety, guaranteeing exercise programs are adapted to individual functional status and medical conditions, with proper screening and monitoring; (3) Duty of collaboration, integrating with physicians, physiotherapists, psychologists, and nutritionists where needed, to respect the principle of multidisciplinary care. This division of roles preserves medical responsibility for diagnosis and clinical safety decisions and recognizes the chinesiologo’s specific competencies in exercise dosing and progression.

The corrective decrees (D. Lgs. 163/2022 [9], 120/2023 [10]) reinforce this framework by clarifying the scope of the chinesiologo’s work (supervision of AFA; focus on psychophysical well-being). Consequently, their accountability increasingly resembles that of recognized health professions, creating the legal basis for malpractice claims if duties are not respected.

5.3. The Role of Ethics Committees in Adapted Exercise and Adapted Sport Projects

When adapted exercise and adapted sport interventions are studied, validated, or implemented in clinical populations, Ethics Committees (Comitati Etici) serve as guardians of participants’ rights and safety. Their functions, defined by EU Regulation 536/2014 [48] and national decrees, extend beyond drug trials to encompass non-pharmacological interventions, including structured adapted exercise and adapted sport programs in hospitals, universities, and community settings.

The role of Ethics Committees in adapted exercise and adapted sport projects is threefold: (1) Assessment of scientific validity, ensuring that adapted exercise and sport interventions are grounded in robust evidence and appropriate methodology; (2) Evaluation of risk–benefit balance, determining whether the physical and psychosocial risks of participation are justified by the potential health benefits; (3) Oversight of consent and privacy, ensuring that participants are fully informed about objectives, risks, and data use, in compliance with the GDPR and Italian privacy law (D. Lgs. 196/2003 [49], as amended by D. Lgs. 101/2018 [50]).

Inclusion of chinesiologi as members of Ethics Committees can provide essential expertise for reviewing adapted exercise and adapted sport interventions, where a nuanced understanding of workload, progression, and adaptation strategies is critical. This would align with the principle of interdisciplinarity in bioethics and strengthen the legitimacy of committee evaluations.

6. Proposal of an Integrated Model for LEA Inclusion

6.1. Rationale

The Italian Constitution guarantees the right to health as a fundamental right of citizenship (Art. 32 [43]), obliging the State to provide essential levels of care (LEA) uniformly across the national territory, as clarified by Constitutional Court judgment n. 282/2002 [46]. Nevertheless, adapted exercise and adapted sport—despite their robust clinical and social benefits—remain excluded from the LEA, producing marked heterogeneity, inequalities, and financial fragility of regional initiatives.

To overcome these limitations, a national framework is needed in which adapted exercise and adapted sport are recognized as a health service rather than a recreational option, where minimum service standards ensure safety, equity, and quality, and where the chinesiologo is formally identified as the professional responsible for planning, delivering, and monitoring exercise programs. Such a framework should also include governance mechanisms that harmonize regional implementation with national guarantees, thereby ensuring that exercise becomes a universally accessible right.

6.2. Structural Components of the Model

The proposed model would target a broad spectrum of populations, including individuals with chronic non-communicable diseases such as cardiovascular, oncological, metabolic, respiratory, and neuromuscular conditions; older adults experiencing frailty or sarcopenia; and people with disabilities who require adapted sport pathways. In addition, preventive strategies should focus on at-risk groups such as sedentary adults, obese children, and workers in high-risk occupational contexts.

Service delivery should occur across multiple settings. Within healthcare, hospitals, rehabilitation centers, and territorial outpatient services would host structured programs, while community-based delivery could be assured through certified Palestre della Salute, municipal gyms, and associations. Educational settings such as schools and universities would play a pivotal role in integrating adapted physical activity into curricula, while digital and telehealth platforms could extend access and continuity of care, especially in underserved areas.

The multidisciplinary workforce is central to the model. The chinesiologo (LM-67 focused on preventive and adapted exercise, and LM-68 on sport and adapted sport) would hold primary responsibility for program design, delivery, and monitoring, working in close collaboration with medical specialists, including general practitioners, physiatrists, oncologists, cardiologists, pulmonologists, and neurologists, who ensure clinical referral and supervision of contraindications. Within this division of labor, the chinesiologo sportivo (LM-68) also delivers adapted sports activity to clinically stable patients, working synergistically with the chinesiologo AMPA (LM-67) during the transition from clinical exercise to community or competitive sport; the two profiles are complementary with no hierarchy.

Program design, dosing/progression, and monitoring of adapted exercise and sport are led by the chinesiologo (LM-67/LM-68). Physicians provide diagnosis, clinical indications, and clinical clearance in higher-risk cases, while physiotherapists deliver physiotherapy (including therapeutic exercise) within rehabilitation. Allied health professionals support comorbidity management, and psychologists and social workers address adherence, motivation, and social inclusion.

Ensuring high-quality provision also requires the definition of explicit service standards. Each patient should undergo a standardized functional assessment, health screening, and risk stratification. Exercise programming should follow the FITT-VP principle (frequency, intensity, time, type, volume, progression), adapted to individual needs. Regular re-evaluation and adverse event tracking must be incorporated into program delivery, with systematic documentation integrated into electronic health records (EHRs). Outcome evaluation should encompass functional capacity, quality of life, social participation, and cost-effectiveness.

6.3. Governance and Financing

At the national level, the Ministry of Health should update the LEA to explicitly include “adapted physical activity and adapted sport under the supervision of qualified professionals (chinesiologi)”.

Referral pathways should avoid physician-only gatekeeping: medical referral/clearance is required when indicated by risk stratification, whereas self-referral or non-medical referral is appropriate for primary prevention and clinically stable chronic conditions, with the chinesiologo conducting standardized screening and coordinating with physicians as needed.

Regional governments would then be responsible for implementation through accredited centers such as Palestre della Salute, co-financed by the Servizio Sanitario Nazionale (SSN; National Health Service) and local health authorities. Financing could adopt a blended model combining SSN coverage, income-sensitive co-payments, and targeted public–private partnerships. To ensure uniform quality, facilities and professionals would undergo accreditation and certification managed through coordinated registers overseen by public authorities, universities, and national sports bodies (CONI, CIP), in collaboration with the Ministry of Health.

6.4. Ethical and Legal Safeguards

The proposed framework must be anchored in ethical and legal safeguards. Equity should be guaranteed so that access is independent of region or socioeconomic status, while safety must be ensured through compliance with professional standards and continuous monitoring. Respect for privacy, particularly in digital monitoring systems, must be guaranteed under GDPR. Accountability would derive from the professional responsibility of the chinesiologo as defined under D. Lgs. n. 36/2021 [8] as amended (163/2022 [9] and 120/2023 [10]). Finally, Ethics Committees should provide oversight for large-scale or experimental exercise projects, ensuring rigorous risk–benefit evaluation and participant protection.

6.5. Expected Outcomes

Integrating adapted exercise and adapted sport into the LEA is expected to yield multiple benefits. Clinically, it would reinforce primary prevention and improve secondary and tertiary management of chronic diseases, reducing hospitalizations and overall healthcare expenditure. For individuals, it would enhance functional independence and quality of life and increase participation in education, work, and community life, especially for people with disabilities. At the system level, it would advance equity by transforming evidence-based exercise- and sport-based interventions into nationally guaranteed rights, standardizing pathways and quality standards across regions, and supporting sustainable financing and transparent outcome monitoring.

6.6. Conceptual Framework

The integrated model for LEA inclusion can be conceptualized as a multi-layered system that connects national policy with local implementation. At the apex lies the Ministry of Health, which has the responsibility to formally update the LEA by including adapted physical activity and adapted sport as essential services, with clear service definitions, minimum quality/safety standards, and sustainable financing mechanisms. This national mandate should be coordinated with the State–Regions Conference to ensure that regional health systems adopt consistent strategies and tools for implementation, while preserving the flexibility to adapt programs to local contexts.

Beneath this national level, accreditation and quality standards constitute the backbone of the model. Facilities and professionals must be certified through coordinated registers overseen by public authorities, universities, and national sports bodies such as CONI and CIP, with periodic re-accreditation based on safety audits and outcome indicators. Accreditation is essential not only for ensuring professional competence and patient safety but also for legitimizing the inclusion of exercise-based interventions within the official healthcare framework.

Service delivery would then be articulated across different domains. Within healthcare settings, hospitals, rehabilitation centers, and territorial outpatient services would provide adapted exercise and adapted sport, where appropriate, as part of prevention and chronic disease management. In the community, certified Palestre della Salute, municipal gyms, and local associations (including para-sport organizations) would act as accessible hubs for ongoing physical activity and adapted sport pathways. Educational settings, particularly schools and universities, would embed adapted exercise into curricula, fostering early adoption and professional training. Finally, digital and telehealth platforms would expand reach, allowing remote supervision, monitoring, and continuity of care for patients unable to access in-person services, including hybrid and tele-supervised formats.

At the operational level, the chinesiologo remains central, with responsibility for the design, delivery, and monitoring of exercise programs (with program design, dosing/progression, and monitoring led by the chinesiologo AMPA (LM-67), in synergy with the chinesiologo sportivo (LM-68) where adapted sport pathways are involved, and medical diagnosis/clearance provided when clinically indicated). This professional role must be fully integrated into multidisciplinary teams that include physicians for clinical referral and oversight, physiotherapists and other allied health professionals for rehabilitation and comorbidity management, and psychologists or social workers for adherence and psychosocial support. Such integration ensures that exercise interventions are safe, effective, and aligned with broader healthcare pathways.

The conceptual framework, therefore, envisions a continuous flow from national policy definition to regional adaptation, from accreditation to service delivery, and from professional responsibility to measurable outcomes, supported by interoperable data systems (EHRs/registries) and standardized outcome metrics. The ultimate objective is to guarantee that citizens, regardless of their region of residence or socioeconomic status, can access adapted exercise and adapted sport as a recognized and enforceable component of the essential levels of care.

7. Discussion

Integrating adapted exercise and adapted sport into the LEA would generate significant benefits for the Italian health system and for citizens’ well-being. From an equity perspective, the establishment of a nationally guaranteed service would ensure that all citizens, regardless of region or socioeconomic status, can access programs designed to improve functional capacity, reduce disability, and enhance psychosocial health. This would overcome the current patchwork of regional initiatives, where opportunities for adapted exercise are concentrated in certain areas, such as Tuscany or Veneto, while others remain underserved. Guaranteeing exercise as a right of citizenship would therefore align practice with constitutional principles of equality in health protection.

Another expected benefit lies in the reduction in healthcare costs. Evidence from cardiac rehabilitation, pulmonary rehabilitation, and exercise oncology demonstrates that adapted exercise reduces hospitalizations, shortens length of stay, and lowers pharmacological expenditure, while improving quality-adjusted life years (QALYs). Cost-effectiveness analyses in multiple disease domains consistently show that supervised exercise interventions are at least as cost-effective as pharmacological treatments, particularly when scaled through community-based facilities. Embedding such programs into the LEA would allow economies of scale, shifting investment from acute and hospital care to prevention and long-term management.

At the individual level, the inclusion of exercise services in the LEA would enhance quality of life, functional independence, and participation in social and working life, particularly for people living with chronic conditions and disabilities. In oncology survivorship, observational evidence shows that nonregular physical activity and lower handgrip strength cluster with greater fatigue and psychological distress; incorporating simple functional measures such as handgrip strength into intake screening can help triage patients to higher-support programming and behavioral counseling [16]. Adapted sport also adds unique value by fostering inclusion, self-efficacy, and community engagement, producing psychosocial benefits that complement physical health outcomes.

However, translating this evidence into national policy requires addressing several structural barriers that directly affect the feasibility of the integrated LEA model proposed in this paper. First, governance fragmentation remains a major obstacle: regional autonomy in healthcare has produced heterogeneous program structures, professional standards, and accreditation pathways. Without nationally mandated criteria for eligibility, supervision, and outcome monitoring, adapted exercise and adapted sport cannot achieve uniform implementation. Second, financing models are currently unstable and dependent on local budgets. LEA inclusion would require a clear, sustainable funding architecture combining SSN coverage, income-sensitive co-payments, and, where appropriate, public–private partnerships. Third, workforce heterogeneity persists. Although the chinesiologo has obtained legal recognition, postgraduate specialization, continuing education, and accreditation remain uneven across regions. Ensuring a competent, nationally distributed workforce is essential for operationalizing LEA inclusion.

Recent legislative developments further illustrate this misalignment. Law n. 149/2025 [51] formally recognizes obesity as a chronic disease and places its diagnosis, care and multidisciplinary management within the LEA. However, while the law emphasizes lifestyle interventions, it does not define structured, adapted exercise pathways nor identify the professionals responsible for delivering them. This confirms the broader argument advanced in this review: the inclusion of chronic conditions within the LEA does not automatically translate into guaranteed access to supervised, evidence-based exercise services unless these are explicitly defined as essential care.

A comparative look at European experiences highlights feasible solutions and Italy’s relative delay. In Germany, physicians can issue a Rezept für Bewegung, a written recommendation and referral (not a medical order) that directs patients to quality-assured exercise programs (e.g., SPORT PRO GESUNDHEIT) delivered by certified clubs, with many courses co-financed by statutory insurers, thereby embedding exercise in routine care [52]. In Sweden, Physical Activity on Prescription (FaR) is a nationwide, guideline-based referral method within healthcare, with individualized exercise plans and structured follow-up [53]. In Norway, municipal Healthy Life Centres (Frisklivssentraler) deliver tailored exercise and behavior-change support on general practitioner referral where indicated, but program design and progression remain with qualified exercise professionals [54].

Among the international systems reviewed, the German model represents the closest and most operationally transferable approach for the Italian context. Unlike prescription-only models, the Rezept für Bewegung functions as a structured, non-medicalized recommendation pathway that directs patients toward certified exercise programs (SPORT PRO GESUNDHEIT) delivered by qualified exercise professionals. This structure parallels the proposed LEA framework for Italy, in which the chinesiologo would lead program design and supervision, while physicians provide referral or clearance only when clinically necessary. The German system also offers two key advantages highly compatible with the Italian SSN: (i) co-financing by statutory insurers, which mirrors Italy’s potential blended financing model (SSN + income-sensitive co-payment); (ii) a national accreditation infrastructure ensuring standardized program quality, which aligns with Italy’s need to unify regional schemes (AFA, Palestre della Salute) under national LEA governance. For these reasons, the German model offers the most operationally transferable blueprint for Italy’s transition from fragmented regional initiatives to a coherent, nationally guaranteed LEA-based system for adapted exercise and adapted sport.

Beyond these well-established systems, several countries—including the United Kingdom, the Netherlands, and Portugal—are currently debating or piloting reforms aimed at formalizing exercise referral pathways, integrating physical-activity specialists into multidisciplinary teams, and exploring reimbursement models for supervised exercise programs. These evolving systems highlight an emerging European trend: the movement from voluntary or project-based initiatives toward regulated, entitlement-based access to exercise services. Italy has not yet initiated a comparable national process, but aligning with this trajectory would require launching a formal pathway for LEA inclusion and establishing coordinated national leadership to bridge the current regulatory implementation gap.

By contrast, Italy has pioneered valuable local experiments, such as Palestre della Salute and AFA, but has not yet consolidated these into a binding nationwide framework. Linking the evidence to the integrated model proposed in this paper, the challenge for Italian policymakers is to institutionalize these regional best practices within a uniform LEA structure that defines minimum service standards, supervision requirements, accreditation criteria, and financing mechanisms. This would ensure that adapted exercise and adapted sport are no longer optional programs but are recognized as fundamental rights within the LEA.

Limitations

This narrative review has several limitations that should be acknowledged. First, the narrative design does not follow a systematic protocol for study selection, which may introduce selection bias and reduce reproducibility. Although we prioritized high-level evidence (guidelines, systematic reviews, meta-analyses, and randomized trials), the absence of formal risk-of-bias assessment limits the ability to compare findings across heterogeneous study designs. Second, international policy contexts vary considerably, and the comparison with European systems inevitably reflects structural, cultural, and regulatory differences that may not be fully transferable to Italy. Third, the translation of legal recognition—specifically the status of the chinesiologo under Legislative Decrees n. 36/2021, 163/2022, and 120/2023—into operational practice remains uncertain within Italy’s highly decentralized regional health system. This decentralization affects governance, accreditation, financing, and workforce distribution, all of which may hinder the nationwide implementation of the integrated LEA model proposed in this paper.

Finally, because policy reform is dynamic, future legislative or regulatory changes may modify the applicability of some arguments presented here. These limitations do not undermine the overall conclusions but highlight the need for ongoing evaluation, updated legal analyses, and empirical assessment of implementation processes as Italy considers integrating adapted exercise and adapted sport into the LEA.

8. Conclusions

This review has argued that the integration of adapted exercise and adapted sport into Italy’s essential levels of care (LEA) is no longer optional but a necessary step to align national health policy with constitutional principles, international recommendations, and the growing body of scientific evidence. Exercise must be recognized as a fundamental component of healthcare, not a recreational supplement, and its provision should be uniformly guaranteed as a right of citizenship.

Central to this vision is the role of the chinesiologo, the university-trained professional in exercise and sport science, who is uniquely positioned to ensure the quality, safety, and inclusiveness of adapted physical activity programs. Recent legislative reforms (D. Lgs. 36/2021 [8], 163/2022 [9], 120/2023 [10]) have formally recognized the chinesiologo’s competencies, but their full realization requires embedding these services within the LEA, thereby transforming recognition into concrete, universally accessible practice.

To move from evidence to implementation, several actionable steps emerge from this review. First, the Ministry of Health should initiate a formal national process for LEA revision that explicitly incorporates adapted exercise and adapted sport as essential services. Second, national–regional coordination mechanisms should be strengthened through the State–Regions Conference, with the definition of minimum service standards, eligibility criteria, supervision requirements, and shared outcome indicators. Third, a phased implementation timeline could guide the transition: (i) short-term (1–2 years): establish national accreditation criteria and draft LEA amendments; (ii) medium-term (3–5 years): scale certified facilities (e.g., Palestre della Salute), expand workforce training, and pilot financing models; (iii) long-term (>5 years): full nationwide rollout supported by interoperable data systems and standardized monitoring.

For policymakers, this implies updating LEA frameworks and guaranteeing stable, sustainable financing through a blended model (SSN coverage plus income-sensitive co-payments). For the SSN, it requires developing accreditation pathways, investing in workforce development, and creating interoperable registries for outcome tracking. For academic institutions, it calls for strengthening curricula, expanding postgraduate training, and supporting research on adapted exercise, adapted sport, and preparing future chinesiologi to operate within multidisciplinary health teams.

By taking these steps, Italy can shift from fragmented, region-dependent initiatives to a coherent national system that positions adapted exercise and adapted sport as pillars of prevention, chronic disease management, and social inclusion, reducing health inequities and healthcare costs and reaffirming that health, including the right to move, is a universal right of citizenship, consistent with the constitutional framework and Constitutional Court case law on essential levels of care. This trajectory would also bring Italy into alignment with emerging European policy trends toward regulated, entitlement-based access to supervised exercise services.