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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:

[email protected]

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-

Copyright1999JournalofOrthopaedic&S

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

Copyright1999JournalofOrthopaedic&S

ports

PhysicalTherapy.Allrightsreserved.


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5/7

.

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

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