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Journal of Orthopaedic Sports Physical Therapy
1999;29(4)
3225-231
Shoulder Pain in FemaleWheelchair
asketball Players
Kathleen
A. Curtis,
PhD, PT1
Kathryn Black,
MS,
0TR2
Study Design: Descriptive self-report survey.
Objectives: To assess activity level, medical history, and the prevalence and intensity of
shoulder and upper extremity pain experienced during functional activities in female
athletes who compete in wheelchairs.
Background: Previous studies have documented a high incidence of upper extremity
soft
tissue disorders in athletes who compete in wheelchairs. None of these studies have
specifically focused on female athletes who use wheelchairs.
Methods nd
Measures: Forty-six female wheelchair basketball players completed an
anonymous survey that included demographic data, medical history data, and the
Wheelchair User's Shoulder k i n ndex (WUSPI). The WUSPl
i s
a valid and reliable self-
report measure scored from 0 to 150, with higher scores indicating a greater intensity of
shoulder pain during functional activities.
Results: The average age of the respondents was 33.2 29.1) years, with an average of 12.5
(+
10.2) years of wheelchair use. Their disabilities included 39 spinal cord injury, 28
various lower extremity musculoskeletal and neuromuscular disabilities, 13 postpolio
paralysis, 11 spina bifida, and 9 amputations. Only 14 of the subjects reported
shoulder pain prior to wheelchair use. In contrast, 72 of the subjects reported shoulder
pain since wheelchair use, with 52 reporting current shoulder pain. Overall, the subjects
scored an average SD performancecorrected total WUSPl score of 15.6 20.5 on a
scale of 0 to 150 points, with 0 representing no pain. The highest intensity of shoulder pain
was reported during household chores, propulsion on ramps or inclines, liking overhead,
and while sleeping.
Conclusions:Shoulder and upper extremity pain was a very common problem reported by
over 90 of the subjects in this study. Prevention of pain and chronic disability in athletes
who use wheelchairs should be addressed by coaches, players, and health care
professionals. Orthop Sports Phys her
l999;29:225 23
1
Key Words:
athletic injuries, spinal cord injuries/complications, paraplegia, upper
extremiy pain
Associate Professor, Department of Physical Therapy, School of Health and Human Services, Cali-
fornia State Universi4 Fresno, Calif.
Occupational Therapist California Children s Services, Alameda Counb Department of Public
Health, Alameda, Calif. Ms. Black was a graduate student at San
lose
State Universi8 San
lose
Calif,
at the time the study was performed.
Send correspondence
to
Kathleen A. Curtis, Department of Physical Therapy, California State Uni-
versi8 Fresno,
2345
East San Ramon Avenue M 6
MH29,
Fresno,
C 9374W031.
E-mail:
C
oss-sectional studies
have reported that a
majority of long-term
wheelchair users ex-
perience upper ex-
tremity pain.
599~11~13
Overuse and
repetitive stress often result in de-
generative soft tissue changes.'
Wylie and Chakra14 observed that
18 of active persons and 45 of
inactive persons with long-term
paraplegia lso showed degenera-
tive changes in the shoulder joint
on radiographs. Other researchers
have reported that wheelchair
users often show chronic degener-
ative injuries to soft tissues, includ-
ing impingement syndromes, rota-
tor cuff tears, sprains, strains, and
avascular necrosi~.l.~J4
Athletes who compete in wheel-
chairs, in particular, experience
frequent upper extremity soft ti s
sue injuries. Participation in
wheelchair basketball, together
with wheelchair track and road-
racing, accounts for the majority
of reported soft-tissue injuries in
athletes in wheelchair^ ^ ^ Wheel-
chair basketball, specifically, is
characterized by intermittent high-
intensity activity for wheelchair
propulsion and maneuvering as
well as reaching overhead for
shooting, passing, and rebound-
ing. These actions put the shoul-
der at risk for overuse injury or
impingement of the soft tissue
structures below the acromion
process as the player reaches over-
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ports
PhysicalTherapy.Allrightsreserved.
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head.3 In addition, the constant stresses of wheel-
chair propulsion on the palmar surface of the hand
often results in symptoms of carpal tunnel
syn
d r ~ m e . ~
Muscle imbalance, in particular, has been implicat-
ed in the pathogenesis of shoulder pain in athletes
who use wheelchair^ ^ Weakness of the external rota-
tor and shoulder adductor muscles contributes to im-
pingement of the supraspinatus tendon beneath the
acromion during humeral ele~ation.~houlder weak-
ness and forces of gravity often lead to an increased
thoracic kyphosis while sitting in and propelling the
wheelchair. This sitting posture, characterized by
scapular protraction and internal rotation of the hu-
merus, may further compromise shoulder motion
during use of the arm.2
Long training hours and busy sports competition
schedules have been associated with increased inci-
dence of injuries in athletes who use wheel~hairs.~J'
Although wheelchair basketball competition began
over 50 years ago, opportunities for women to partic-
ipate in wheelchair have recently increased both na-
tionally and internationally. Elite women basketball
players have competed in
3
world championships
and 3 Paralympic Games in the past 10years.14
Chronic overuse and injury during sports contrib-
ute to the development of upper extremity pain,
which interferes with function in the long-term
wheelchair user. Full-time wheelchair users depend
on the integrity of their upper limbs for their daily
i n d e p e n d e n ~ e . ~ J ~ J ~hese wheelchair users are not
only prone to developing shoulder pain; they may
not be able to rest an injury sufficiently to allow for
it to heal without further strain and reinjury.
Several studies have shown that shoulder pain is a
limiting factor in the daily activities of individuals
with paraplegia, especially during transfers and
w h ee lch a i r p r o p u l s i~n . ~~~ . ~~e could find only 1 arti-
cle that studied shoulder pain in women who use
wheelchairs. Pentland et all3 reported that women
with paraplegia experience difficulty because of
shoulder pain with work and school activities, out-
door wheeling, household work, reaching and lifting,
driving, loading the wheelchair into the car, and
transferring between the wheelchair and the car or
bed. Although female subjects have been included in
most studies on wheelchair athletes, no studies have
specifically focused on shoulder pain in female ath-
letes who use wheelchairs. Additionally, some athletes
who have unilateral amputations or lower extremity
musculoskeletal and neuromuscular disorders use
wheelchairs only for sports participation and are am-
bulatory for daily activities. Shoulder pain in these
ambulatory athletes has not been compared with
shoulder pain in athletes who are full-time wheel-
chair users.
The purpose of our study
was to assess activity lev-
el, medical history, and the prevalence and intensity
TABLE
1.
Characteristics of subiects n 46 .
Disability group
Spinal cord injury 18 39.1
Lower extremity muxuloskeletal and 13 28.3
neuromuxular disabilities
Polio 6 13.0
Spina bifida 10.9
Amputation 4 8.7
Marital status
Single 32 69.5
Married
9 19.6
Divorced 10.9
Occupation
Employed 26 57.8
Student 12 26.7
Volunteer
2 4.4
Retired 2.2
Other
4 8.9
of shoulder and upper extremity pain in female
wheelchair basketball players. We hypothesized that
age, years of wheelchair use, and high activity levels
would
be
positively associated
wi th
higher intensities
of shoulder pain during functional activities. We fur-
ther hypothesized that subjects with disabilities re-
quiring full-time wheelchair use (such as spinal cord
injury and spina bifida) would report more intense
shoulder pain than subjects with disabilities that al-
lowed them to be ambulatory when not competing
in basketball.
METHODS
Subjects
Forty-six of 94 (48%) female wheelchair basketball
players who received surveys at the 1997 National
Women's Wheelchair Basketball Tournament partici-
pated in this descriptive study to assess their experi-
ence with shoulder pain. Questionnaires with a cover
letter were distributed when participants checked in
for the Steam basketball tournament. Several assis-
tants encouraged subjects to complete and return
the questionnaires during the tournament. Question-
naires were collected on-site before the end of the
tournament.
The average age of the respondents was 33
C
9
years. The average years of wheelchair use was 13
10 years. The characteristics of the respondents in-
cluding the type of disability, marital status, and oc-
cupation are presented in Table 1.
Instrumentation and Procedures
The Wheelchair User's Shoulder Pain Index
(WUSPI), a Is item, valid, reliable instrument was
used to measure shoulder Each of the 15
J
Orthop Sports hys
Ther Volume
29
Number
4
April
999
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TABLE 2.
Wheelchair User's Shoulder Pain Index items.
Based o your experiences in the past week
how
much
shoulder pain do you experience when:
the Committee for the Protection of Human Subjects
at California State University, Fresno.
1. Transferring from a
bed
to a wheelchair?
2. Transferring from a wheelchair to a car?
3. Transferring from a wheelchair to the tub or shower?
4. Loading your wheelchair into a car?
5. Pushing your chair for 10 minutes or more?
6. Pushing up ramps or inclines outdoors?
7.
Lifting objects down from an overhead shelf?
8. Putting on pants?
9. Putting on a T-shirt or pullover?
10. Putting on a button-down shirt?
11. Washing your back?
12. Usual daily activities at work or school?
13. Driving?
14. Performing household chores?
15. Sleeping?
Each item is followed by
a 10-cm
visual analog scale, anchored at no
pain and worst pain ever experienced.
items represents the subject's perception of shoulder
pain during a functional activity, such as wheelchair
to automobile transfers, wheeling on inclines, don-
ning articles of clothing, or lying on the shoulder
while sleeping. Subjects mark a lOcm visual analog
scale, anchored at no pain and worst pain ever
experienced. Each item is scored and scores of the
individual items are added, to yield a total score
from 0 to 150, with 0 representing no pain (Table
2).
Previous studies have determined that the WUSPI
has high test-retest reliability (ICC 0.99) and shows
high internal consistency a 0.97) 6.7 study of
concurrent validity showed statistically significant
negative correlations r -0.49 and -0.48) be-
tween subject WUSPI scores and goniometric mea-
surements of active shoulder abduction and flexion,
respec i~ely.~
Subjects completed a demographic questionnaire
including age, gender, marital status, level of injury,
years of wheelchair use, number of daily wheelchair
transfers, and hours per week spent at work, sports
and leisure activities, and driving. They also complet-
ed a medical history questionnaire that assessed his-
tory of shoulder injury and current status of shoul-
der pain and upper extremity pain, including treat-
ment received. We followed procedures approved by
TABLE
3. Activity level and exposure characteristics of subjects
n
46).
Data Analysis
Subject demographic characteristics, activity levels,
and medical history data were analyzed using de-
scriptive statistics. Following measurement of individ-
ual item scores in centimeters with a standard ruler,
scores were rounded to the closest millimeter and
added to yield a total WUSPI score. Performance-cor-
rected WUSPI scores were calculated by correcting
for activities not performed. Group means were cal-
culated for individual items and total and perfor-
mance-corrected WUSPI scores. series of Pearson's
product moment correlations were calculated to ana-
lyze the relationship of age, years of wheelchair use,
and activity levels to subject WUSPI scores. An alpha
level of .05 was used for all analyses to determine if
correlation coefficients were significantly different
from 0.
RESULTS
Activity Level
Subjects participated in work and school for an av-
erage of 30 16 hours and in sports and leisure ac-
tivities for an average of 11 + 7 hours per week.
They spent an additional 10
+
7 hours per week
driving. Their daily activities required an average of
15 13 wheelchair transfers per day (Table 3) .
Prior and Current Upper Extremity Pain
Only 6 (14%) subjects reported shoulder pain pri-
or to wheelchair use. In contrast, 33 (72%) subjects
reported shoulder pain since wheelchair use, with
52% reporting current shoulder pain. Only 11% not-
ed that their shoulder pain had limited their perfor-
mance of activities in the preceding week.
Over 70% of the subjects also reported a history of
hand or elbow pain or both since beginning wheel-
chair use. Only 4 players (9%) had not experienced
shoulder, elbow, or hand pain or injuries since using
the wheelchair (Table 4).
Mean SD Minimum Maximum
Age,
33 2
9.1 18 52
Years of wheelchair use 12.5 10.2 1 45
Activity lwel
Number of wheelchair transfers per day 14.8 13.4 0 45
Hours per week of work and school 30.1 16.6 0 60
Hours per week of sports and leisure 10.8 7.1 2 30
Hours per week of driv ing 9.8 6.7 0 27
J Orthop
ports
Phys Ther Volume 29.Number 4.April 999
227
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ports
PhysicalTherapy.Allrightsreserved.
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.
R.pohdRlnhFandoWlmkhdr8.rk. b.llPlywr
per week spent at work or school or sports and lei-
sure activities were small and not statistically signifi-
FIGURE 1. Of 46 female wheelchair basketball players, 41 reported upper
extremity pain since beginning wheelchair use. Women with a history of
shoulder pain since wheelchair use had higher performance-corrected
mean Wheelchair User Shoulder Pain Index (PC-WUSPI) scores
18.9
22.1)
than did women who did not report shoulder pain since wheelchair
use
6.5 11 a).
Women with current shoulder pain had higher PC-WUSPI
scores 26.3 22.6) than did women who did not report current shoulder
pain 3.2 6.2). Women who reported a history of hand or elbow pain
since wheelchair use had higher PC-WUSPI scores 1 8.0 22.4) than did
women who d id not report hand or elbow pain since wheelchair use 10.9
15.0).
.
cant
P
> .05).
Although significant, there was a weak positive cor-
relation ( r
=
300, P = .05) between performance
corrected WUSPI score and transfers performed per
day. Further analysis revealed that the 33 subjects
who reported experiencing shoulder pain since be-
ginning wheelchair use averaged 16 wheelchair trans-
fers per day compared to 11 transfers per day in the
13 subjects who did not have a history of shoulder
pain.
The correlation between hours of driving per week
and performance-corrected WUSPI score was also
weak but statistically significant ( r = 388, P
=
.01).
Comparison of shoulder pain history showed that
those athletes who had reported a history of shoul-
der pain since beginning wheelchair use reported an
average of 11.1 hours of driving per week, compared
to 6.6 hours of driving per week in those who had
not experienced shoulder pain. Multiple regression
analysis showed that these 2 variables-transfers per
day and hours of driving per week-together ac-
counted for 22.1 of the variance in performance
corrected WUSPI score.
Comparison of Shoulder Pain, Exposure, and Activity
Level by Athlete Disability
Shoulder Pain, Exposure, and Activity Level
The WUSPI scores of subjects by ambulatory status
and disability group are presented in Figure 2 The
To investigate the relationship of years of experi-
ence and activity level to shoulder pain, a series of
Pearson's product moment correlations were calcu-
lated between performance-corrected WUSPI score
and subjects' age, years of wheelchair use, daily trans-
fers performed, hours per week spent at work or
school, sports and leisure activities, and driving (Ta-
ble 6). The correlation coefficients between WUSPI
score and age, years of wheelchair use, and hours
subjects with amputations (who are likely to be
am-
bulatory) averaged a WUSPI score twice that of any
other disability group. In contrast, subjects with dis-
abilities such
as
spinal cord injury and spina bifida,
who are likely to use a wheelchair full-time, did not
report higher WUSPI scores than did subjects with
disabilities who are likely to be ambulatory, such
s
those with amputations or lower extremity muscule
skeletal and neuromuscular disorders.
TABLE 6. Correlations of age, years of exposure, and activity lwel with performancecorrectedWUSPI score.
Correlation with
Performancd:Orrecfed
Coefficient
of
WUSPl
Score Detennination
Variable Pearson s (1 1 PValue
Age
Years in wheelchair
Activity lwel
Number of wheelchair
transfedday 0.300* 0.08 .05
Hours per week of
work and school -0.064 0.004 .68
Hours per week of
sports
and leisure 0.237 0.06 .12
Hours per week of
driving 0.388* 0.15 .O1
* P