Shoulder pain, functional capacity and quality of life in ...

Research article

Shoulder pain, functional capacity and quality of life in professional wheelchair basketball players and non-athlete wheelchair users Ozlem Ustunkaya, Ayse Ozcan Edeer, Hulya Donat, Nuray Yozbatiran School of Physical Therapy and Rehabilitation, Dokuz Eylul University, Balcova, Izmir, Turkey

Background and Objective: Wheelchair users are exposed to many stresses on their upper extremities. The appearance of shoulder pain related to these stresses could affect their functional capacity and quality of life. The aim of this study was to investigate the shoulder pain and compare the shoulder pain, functional capacity and quality of life between wheelchair basketball players and non-athlete wheelchair users. Methods: Twenty-five wheelchair basketball players (athletes) from professional leagues and 23 nonathlete wheelchair users were included in this study. The subjects’ shoulder pain was assessed with the Wheelchair User’s Shoulder Pain Index. Timed Forward Wheeling, Forward Vertical Reach and 1Stroke Push tests were used to measure functional capacity, and the Satisfaction with Life Scale was used to evaluate their quality of life. Results: No differences were found in Wheelchair User’s Shoulder Pain Index and Satisfaction with Life Scale score between the athletes and non-athletes (P > 0.05). The scores of functional capacity, height in forward vertical reach test, 1-stroke push distance, and timed forward wheeling were better in the athlete versus the non-athlete group (P < 0.05). Conclusions: Although significantly higher functional capacity is seen in athlete versus non-athlete wheelchair users, their shoulder pain and quality of life may be similar. Keywords: wheelchair, basketball, shoulder pain, functional capacity, quality of life

Introduction Wheelchair users are exposed to many stresses on their upper extremities during pushing their wheelchair, carrying weight and other activities of daily living. Because of these stresses, soft tissue injuries and degenerative joint diseases of the shoulder often occur.1 For instance, research has shown that repetitive overhead activities with other contributing factors like abnormal positioning of the shoulder, posture, age, Correspondence to: Ayse Ozcan Edeer PhD, Associate Professor, School of Physical Therapy and Rehabilitation, Dokuz Eylul University, Balcova, Izmir 35340, Turkey E-mail: [email protected]

© 2007 W.S. Maney & Son Ltd DOI 10.1179/016911107X268657

compression and ischaemia can cause rotator cuff irritations in wheelchair users.2,3 After these injuries and traumas, chronic pain usually appears in the upper extremities of wheelchair users, causing some difficulties in daily activities like pushing, driving, dressing and transferring.3–6 The functional levels of wheelchair users could be much lower when compared to those of other handicapped people. Both low functional level and upper extremity pain causing difficulties in activities of daily living negatively affect wheelchair users’ quality of life. In addition, sedentary wheelchair users with low functional capacity tend to experience more upper extremity pain due to weak muscles. Wheelchair users can also participate in different sports activities, such as athletics, basketball,

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Shoulder pain, functional capacity and QoL in professional wheelchair basketball players and non-athlete wheelchair users

swimming, tennis, marksmanship, rugby, sailing and winter sports.7–9 These kinds of sports increase motivation, functional capacity and improve quality of life. However, besides the injuries related to wheelchair usage in daily activities as mentioned above, athlete wheelchair users can also be affected from some injuries and over-use traumas related to the sports activities.1,10 This is especially true in basketball, which includes shooting and rebound activities which require repetitive or static shoulder elevation, causing impingement, rotator cuff and bicipital degeneration.11–13 Some activities of daily living, including using their wheelchair and sleeping, become painful for basketball wheelchair players.14 Curtis and colleagues15 studied 19 wheelchair basketball players with spinal cord injury (SCI) and 19 non-athlete wheelchair users. They reported less medical attention and decreased hospital stay, an increase in functional skills, and indicated that sports activity is protective against sedentary risk factors like obesity and cardiovascular diseases in wheelchair basketball players.15 While better functional capacity is a contributing factor in decreasing shoulder pain, shoulder pain related to sports activities can decrease the quality of life. Defining the shoulder pain, the functional capacity and the quality of life in the population of wheelchair basketball players should give some important information that can be used to offer sports activities to wheelchair users. However, there are few studies about differences in pain, functional activity and quality of life between wheelchair basketball players and non-athlete wheelchair users. As a result, we aimed to investigate shoulder pain and compare the shoulder pain, functional capacity and quality of life in wheelchair basketball players and non-athlete wheelchair users.

Materials and Methods Subjects

The study was carried out on 48 male subjects (25 wheelchair basketball players and 23 non-athlete wheelchair users) between January and September 2005 in Izmir. The inclusion criteria were being at least 18 years old and handicapped for at least the last year, having no mental disorders, having the ability of to read and write, and use of a wheelchair in more than 50% of daily activities. Twenty-five wheelchair basketball players (mean age, 28.96 ± 4.70 years) who were members of four professional sports clubs (Izmir Municipality Sports Club, Rehabilitation Sports Club, Karsiyaka The

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Handicapped Sports Club, Baris Gucu Sports Club) were included in the study. Eighteen of 43 professional wheelchair basketball players were excluded from the study because of using their wheelchair in less than 50% of their daily activities. Twenty-three non-athlete wheelchair users (mean age, 35.00 ± 11.37 years) who were members or nonmembers of several associations for the handicapped were evaluated. Addresses and phone numbers of 132 handicapped individuals were obtained from Izmir Governorship Center of the Handicapped and associations for the handicapped; 94 of them were contacted. Among the 94 handicapped individuals, there were 18 who had a mental disability, 29 who were under 18 years of age, one who was not co-operative, 15 who were using their wheelchair in less than 50% of their daily activities, five who had 100% disability, one who did not volunteer, and two who were blind that were excluded from the study. A detailed medical history revealed the following information: shoulder pain before and after becoming a wheelchair user was found to be similar in both groups (athletes and non-athletes – before 12% and 9% and after 60% and 70%, respectively). Only one subject in the athlete group has had shoulder surgery. Of the athletes, 44% reported current shoulder pain, whereas only 17% of the non-athletes had current shoulder pain. Professional medical attention was sought in 72% of the athlete group versus 65% in the non-athlete group. Restriction of daily activities due to shoulder pain within the last week occurred in 6 subjects (24%) in the athlete group, whereas many fewer subjects (2 subjects; 9%) in the non-athlete group reported restriction. When the subjects were further interviewed for the existence of pain at the elbow or hand after becoming a wheelchair user, almost all of the subjects (92%) in the athlete group reported pain in the elbow or hand, and only half of the subjects (52%) in the non-athlete group. The Ethics Committee of Dokuz Eylul University approved this study. Information about this study was given to the subjects. Procedure

After recording the demographic and medical information, shoulder pain, functional capacity and quality of life were evaluated. A questionnaire was used to note demographics and medical history.16,17 Demographics included age, gender, body mass index (BMI), marital status, duration of wheelchair usage, type of handicaps, frequency of wheelchair transfers per day, and hours per week spent at work and/or school, in sporting/recreational activities and driving.

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In the medical history, the following items were noted: the shoulder pain felt before using the wheelchair, the shoulder pain felt during the wheelchair usage, the shoulder pain felt at the present time, whether or not an individual was getting medical help to avoid the shoulder pain, the activities done to avoid the shoulder pain, whether or not the shoulder pain restricted daily activities in the last week, and whether there was any pain or wound either of the hand or elbow because of using a wheelchair. The Wheelchair User’s Shoulder Pain Index (WUSPI) was used to assess the intensity of pain during activities of daily living. The WUSPI, which includes five items, was described and shown to be valid and reliable by Curtis et al.16 A performancecorrected WUSPI (PC-WUSPI) was calculated and used for analysis. In order to describe the functional capacity, three tests, which were improved by May et al.18 for functional works, were used in our study: (i) timed forward wheeling (time to wheel as quickly as possible over a 23-m linoleum surface); (ii) forward vertical reach (height measured from the floor attained when participants held a measuring stick in a horizontal position with both hands, raising it forward and up as far as possible); and (iii) one-stroke push (distance completed with one maximal push on a carpeted surface). To avoid upper-extremity fatigue, participants were given a rest between tests. Ramp ascent activity, which is the fourth test described by May et al.18 for functional work, was not used in this study because it was not practical. Quality of life was measured with the Satisfaction with Life Scale (SWLS).19 The SWLS is a well-validated measure of subjective satisfaction with life that allows respondents to weigh domains of their lives in terms of their own values. The SWLS consists of five statements measured on a 7-point Likert scale (ranging from 1 [completely disagree] to 7 [completely agree]); the total score can, therefore, range from 5 to 35. Statistical analysis

The Mann–Whitney U-test was used to compare the demographics, the WUSPI subscores and PC-WUSPI Table 1

scores, the functional capacity and the satisfaction with life between the wheelchair basketball players and non-athlete wheelchair users. For all tests, significance was set 0.05. SPSS v.11 (Statistical Package for Social Sciences) was used for the statistical analyses.

Results In total, 48 subjects were evaluated – 25 athlete wheelchair basketball players and 23 non-athlete wheelchair users. There was no statistically significant difference between the groups regarding age, number of transfers and total time for using the wheelchair. The results revealed that the BMI of the non-athlete group was significantly higher than that of the athlete group. In addition, the time spent for school/work and sports or recreational activities was found to be significantly higher in the athlete versus the non-athlete group (P < 0.05; Table 1). The marital status, type of wheelchair used, type of disability, driving and employment status of the groups are given in Table 2. There was no difference between groups regarding the WUSPI subscores (Table 3). Additionally, there was no difference in PC-WUSPI and quality of life between the two groups. However, the height in forward vertical reach test and 1-stroke push distance were found to be higher and the time for the forward wheeling test was found to be less in the athlete versus the non-athlete group (P < 0.05; Table 4).

Discussion In our study, 25 athlete and 23 non-athlete wheelchair users were compared to determine differences in shoulder pain, functional capacity and quality of life. We found that functional capacity was significantly higher in wheelchair basketball players than nonathlete wheelchair users, whereas shoulder pain and quality of life did not differ between the groups. It was

Demographic information of the athletes and non-athletes Athletes (n = 25)

Age (years) BMI (kg/m2) Number of transfer (times per day) Duration of wheelchair use (years) Work and/or school (h/week) Sporting/recreational activities (h/week)

Non-athletes (n = 23)

28.96 ± 4.70 21.10 ± 2.32 9.60 ± 12.62 11.18 ± 6.07 34.52 ± 25.52 9.70 ± 3.74

35.00 ± 11.37 25.40 ± 7.06 6.39 ± 4.41 11.63 ± 8.32 19.71 ± 28.99 8.54 ± 10.62

P-value NS < 0.05 NS NS < 0.05 < 0.05

Values are mean ± SD; P-values from Mann Whitney U-test; NS, not significant.

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Table 2


Marital status, type of wheelchair, type of disability, driving and employment status of the athletes and non-athletes Athletes

Marital status

Single Married Divorced Widowed Manual Manual and power SCI Polio Amputation Spina bifida Other Yes No Official Student Retired Volunteer Other

Type of wheelchair Type of disability

Driving Employment status

Table 3

n = 25

%

Non-athletes n = 23 %

12 13 – – 25 – 2 18 3 0 2 7 18 13 2 2 1 7

48.0 52.0 – – 100 – 8.0 72.0 12.0 0 8.0 28.0 72.0 52 8 8 4 28

13 6 2 2 20 3 11 1 5 2 4 7 16 6 5 5 1 6

57.0 26.0 9.0 9.0 87 13 47.8 4.3 21.7 8.7 17.4 30.0 70.0 26 22 22 4 26

The comparison of WUSPI subscores of groups

Transferring from bed to a wheelchair Transferring from a wheelchair to car Transferring from a wheelchair to the tub or shower Loading the wheelchair into a car Pushing your chair for 10 min or more Pushing up outdoor ramps or inclines Lifting objects down from an overhead shelf Putting on pants Putting on a T-shirt or pullover Putting on a button-down shirt Washing your back Usual daily activities at work or school Driving Performing household chores Sleeping

Athletes (n = 25)


1.00 ± 2.30 0.50 ± 1.58 1.50 ± 2.59 2.25 ± 3.07 3.04 ± 2.98 2.58 ± 2.68 2.08 ± 3.21 0.41 ± 1.41 0.62 ± 1.46 0.45 ± 1.28 1.70 ± 2.61 1.12 ± 1.67 0.60 ± 1.34 0.58 ± 1.50 1.95 ± 2.36

0.88 ± 2.23 0.85 ± 2.08 0.14 ± 0.53 Not performed 2.42 ± 2.97 3.88 ± 3.58 0.89 ± 2.60 0.26 ± 1.14 0.45 ± 1.47 0.33 ± 1.15 4.06 ± 13.73 1.90 ± 2.38 3.12 ± 3.04 1.25 ± 2.31 2.30 ± 3.02

P-value NS NS NS NS NS NS NS NS NS NS NS NS NS NS

WUSPI, Wheelchair User’s Shoulder Pain Index. Values are mean ± SD; P-values from Mann Whitney U-test; NS, not significant. Table 4

The comparison of scores of the PC-WUSPI, the SWLS and functional tasks

PC-WUSPI SWLS Functional tasks Timed forward wheeling (s) Forward vertical reach (cm) 1-stroke push (cm)

Athletes (n = 25)


21.59 ± 20.71 21.12 ± 6.02

20.84 ± 22.35 21.34 ± 6.87

7.23 ± 1.19 126.07 ± 13.75 583.69 ± 173.89

16.52 ± 10.87 114.21 ± 17.68 238.45 ± 94.76

P-value NS NS < 0.001 < 0.001 < 0.001

PC-WUSPI, Performance-Corrected Wheelchair User’s Shoulder Pain Index; SWLS, Satisfaction with Life Scale’ Values are mean ± SD; P-values from Mann Whitney U-test; NS, not significant.

important that there was no statistically significant difference between the groups regarding age, number of transfers and total years of using the wheelchair. However, amongst the demographic information, the distribution of some types of disabilities (e.g. SCI and

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polio) showed differences between the groups, which might have affected the study results. As expected, because the time spent for school/work and sports or recreational activities was higher in athletes, their BMI was lower and functional capacity was better than

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those of the non-athlete group. The functional task test that was developed and proven reliable by May et al.18 in 2003 was used in our study. As the functional tasks of groups were compared, it was seen that athletes showed much better performances in the forward vertical reach, 1-stroke push and timed forward wheeling tests than non-athletes. This result suggested that basketball playing increases functional levels in wheelchair users. Because the BMI of nonathletes was higher than athletes, it could be thought of as another reason why athletes showed better performance in the functional tasks. On the other hand, it could be thought that basketball playing decreases body mass index in wheelchair users. In the literature, there are many studies reporting shoulder pain in wheelchair users. Curtis and colleagues6 reported shoulder pain when pushing the wheelchair for 10 min or more, sleeping, and pushing up ramps in 195 wheelchair users with SCI. In another study, Curtis and colleagues14 reported shoulder pain in other activities, such as household activities, pushing up ramps, lifting objects down from an overhead shelf and during sleep in 46 female wheelchair basketball players. Gironda and colleagues5 noted shoulder pain during wheelchair mobility and transfer activities. Finley and colleagues10 found shoulder pain during sleeping, transfer activities, lifting 5 litres, and lifting an object down from an overhead shelf in athlete wheelchair users. Similarly, in our study, athletes stated shoulder pain during pushing the wheelchair for 10 min or more, pushing up outdoor ramps and inclines, and loading the wheelchair into a car, etc., whereas non-athletes stated shoulder pain during washing their back, pushing up outdoor ramps or inclines, driving, etc. However, there was no significant difference in any WUSPI item between the groups. Dyson-Hudson and colleagues20 found that the PCWUSPI scores were 48.9 ± 24.6 in 18 subjects with SCI suffering from shoulder pain, while Curtis and Black14 reported that the PC-WUSPI score was 15.6 ± 20.5 in 46 female basketball players with different disabilities, including spinal cord injury, various musculoskeletal and neuromuscular extremity disabilities, post-polio paralysis, spina bifida, and amputations. In our study, the PC-WUSPI score was 21.59 ± 20.11 in the athlete group and 20.84 ± 22.35 in the non-athlete group. The reason we think our WUSPI scores were closer to those of Curtis and Black14 is that our study also consisted of subjects with different pathologies, like poliomyelitis, amputation, and spina bifida, in addition to SCI. In addition, another interesting finding in our study was

the similarity of the PC-WUSPI scores between athletes and non-athletes. Thus, we thought that the shoulder pain might not be related to basketball playing but to the use of a wheelchair. We suggest that basketball playing has no negative or positive effect on the shoulder pain. Another point of view worth mentioning is that, although shoulder pain evaluated with WUSPI did not differ between the groups in our study, the pain reported in the medical history was not similar between the groups in some aspects. In both groups, the reported shoulder pain seemed to increase after becoming a wheelchair user. However, the percentage of reported current shoulder pain, medical attention, restriction of daily living activities and presence of hand/elbow pain since becoming a wheelchair user seemed to be higher in the athlete group. It is generally known that sports activities have a protective effect due to strengthening of the muscles, and can improve the quality of life in many ways when compared to a sedentary wheelchair user. On the other hand, it can be thought that because of the extra musculoskeletal stresses related to sports activities, the same or more pain appears in athlete wheelchair users that, as a result, can affect activities of daily living and quality of life. Although athlete wheelchair users have significantly higher functional capacity, which is expected to increase the quality of life, athlete wheelchair users’ shoulder pain would be similar or show a higher incidence than in non-athlete wheelchair users. Therefore, the quality of life may not differ between athlete and non-athlete wheelchair users. Vogel and colleagues21 reported SWLS score of 22.7 in 46 wheelchair users with SCI and Putzke and colleagues,22 who followed 940 subjects with SCI for 2 years, found SWLS score of 17.3. In our study, wheelchair users’ SWLS scores were similar to those of previous studies. In addition, no significant difference in SWLS scores was found between athletes and nonathletes (21.12 in athletes, 21.34 in non-athletes). In general, quality of life is related not only to physical functions but also age, marital status, social security, work, income, family, social integration, environmental structure, type of handicap and the reason for handicap.21,22

Conclusions There is no difference between the PC-WUSPI and SWLS scores of athletes and non-athletes using wheelchairs, and athletes have better performance on functional task tests. It is concluded that basketball

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playing does not affect the shoulder pain and quality of life of wheelchair users, but it does improve functional capacity. It is thought that doing the study on more subjects could yield different results.

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