Shoulder pain in wheelchair basketball athletes: A scoping review

Abstract

Context

Wheelchair basketball athletes have increased upper limb stress, which frequently leads to shoulder pain.

Objective

The purpose of this scoping review was to summarize the existing literature on shoulder pain in wheelchair basketball athletes.

Methods

We searched PubMed, Cochrane Library, Scopus, and PEDro databases for studies performed between January 1990 and February 2021. Two independent reviewers screened the studies according to the inclusion and exclusion criteria. Participants’ characteristics and results were extracted from the study.

Results

The initial database search yielded 2455 articles, 11 of which met the inclusion criteria. This review included seven studies in its final analysis; among them, seven determined the prevalence and incidence of shoulder pain, five investigated the factors and mechanisms contributing to shoulder pain, and two reported the treatment and preventive measures. The prevalence of shoulder pain in wheelchair basketball players ranged from 38%−75%, and the incidence of shoulder pain was 14%. Factors/mechanisms included overuse, decreased trunk control, and driving posture. Treatment/preventive measures consisted of shoulder and scapular muscle strengthening and stretching exercises. However, the literature on treatment/prevention was scarce, and its effectiveness was unclear.

Conclusion

This scoping review confirmed the high prevalence of shoulder pain in wheelchair basketball players; despite this, studies regarding treatment or preventive measures remain lacking. Further studies investigating the mechanism of onset of shoulder pain and the effectiveness of therapeutic and preventive measures are needed in the future.

Introduction

Wheelchair users have a lot of burden on their weight-bearing upper limbs in activities of daily living. Patients with spinal cord injury (SCI) who use wheelchairs often complain of shoulder pain, and its prevalence has been reported to be approximately 30-70%.^1–3 Previous studies have reported a significantly higher prevalence of rotator cuff tears in paraplegic patients compared to healthy individuals.^4,5 Thus, these reports suggest that shoulder pain is a serious problem for individuals with SCI.

Participating in adaptive sports improves physical function and quality of life (QOL) in individuals with SCI^6,7; however, it may also cause increased risk of acute trauma and overuse of the upper extremities.⁸ In athletes who participated in the 2016 Rio de Janeiro Summer Paralympics, the shoulder had the highest incidence of injury.⁹ Overhead sports (such as wheelchair basketball [WB] and tennis) require overhead actions and high-intensity activities, which increase the risk for shoulder pain. Additionally, other studies have reported that regardless of sport level, overhead athletes are at an increased risk of developing injuries involving the rotator cuff and labrum.^10,11 Overhead action increases the shoulder’s risk for overuse injury; additionally, the reaching action can cause soft tissue impingement below the acromion process.

WB is an adaptive sport known worldwide, in which there is an increased burden on the upper extremities due to the actions involved, such as passes, shots, rebounds, and rapid wheelchair manipulation.¹² Physical disabilities are a prerequisite for WB athletes, such as SCI, congenital deformities, post-polio syndrome, or lower limb amputation. SCI athletes participating in WB usually perform repetitive overhead motions, which increases the risk of shoulder pain.¹³ In addition, for patients with disabilities, especially wheelchair users, the upper body and shoulder complex are utilized in most tasks involving sports and activities of daily living. Therefore, proper management of shoulder pain is an important factor to improve the QOL of many individuals. Considering these relationships, there is a need to improve the knowledge regarding shoulder pain to help wheelchair users better cope with shoulder pain associated with WB. However, there is a lack of research on shoulder pain in WB athletes. Therefore, this scoping review aimed to examine the literature to determine the current knowledge regarding shoulder pain in WB athletes and to direct future research in this area.

Materials and methods

The scoping review was conducted according to previously developed guidelines and the PRISMA extension for Scoping Reviews (PRISMA-ScR).^14,15 We searched the PubMed, Cochrane Library, Scopus, and PEDro databases. The search period was defined as the period between January 1990 and February 2021, referring to previous studies.¹⁶ The search strategy used a combination of Medical Subject Headings and keyword searches using the following search terms: shoulder, upper extremity, pain, injury, complaint, wheelchair, basketball, exercise, and rehabilitation (see Supplementary Table). Two authors (MK and OT) independently screened the titles and abstracts of the identified studies. Furthermore, the full-text of the studies that qualified after the first screening were further evaluated according to the predefined inclusion and exclusion criteria. The two authors compared their lists, and any differences in opinion were resolved by discussion; if a consensus was not reached, a third author arbitrated the decision (JK). In addition, references from eligible articles were searched to ensure a comprehensive survey of the relevant literature.

The inclusion criteria were as follows: (1) the research target in the study was clearly documented as a WB athlete under the categories ranging from recreational to elite and (2) the articles that documented the prevalence, incidence, causative factors, treatment, and preventive measures of shoulder pain. The exclusion criteria were as follows: (1) articles that included WB athletes in combination with athletes of other disability sports; (2) case report articles; and (3) articles written in languages other than English.

Article titles were screened, and titles that clearly did not satisfy the eligibility criteria were excluded. The abstracts of the remaining articles were then reviewed, and the same eligibility criteria as before were used to exclude the articles. In addition, the remaining articles were full-text reviewed, and articles that did not contain information related to our review were excluded.

Quality assessment was performed independently by two reviewers using an adapted version of the checklist developed by Webster et al.¹⁷ The following aspects were evaluated in the checklist: participant characteristics, inclusion and exclusion criteria, study design, key dependent variables, reliability, validity, external validity, and limitations of the studies.

To extract relevant data from the eligible studies on shoulder pain, a supplementary table was created to summarize the following details: (1) author and year of publication, (2) study design, (3) sample size, (4) participant characteristics, (5) sample extraction, (6) prevalence or incidence, (7) causative factors, (8) treatment, and (9) preventive measures. Before creating the table, we extracted data from several studies using a data extraction form and tested the data for any problems. One reviewer (MK) extracted all the data, and a second reviewer (OT) assessed the data extraction for any discrepancies. Discrepancies in data extraction were resolved by reviewing the source data.

Results

The initial search yielded 2455 records from the four databases. After duplicates were removed, 1751 records remained. We screened 35 full-text articles and identified 11 studies that were included in the scoping review (Figure 1). Among the 11 articles, seven studies^13,18–23 reported the prevalence and incidence, five studies^{13,18,20,22,24} reported factors and mechanisms, and two studies^25,26 reported treatment and preventive measures. Of all included studies, one was a non-randomized controlled trial,²⁶ one was a study that included a pre-test and post-test model,²⁵ eight were cross-sectional studies,^{13,18–21,23,24,27} and the remaining one was a prospective cohort study.²² Regarding the outcome measures, five trials used the Wheelchair User's Shoulder Pain Index (WUSPI)^{18–20, 23,24} and range of motion^{13,21,23,25,26}; two trials used the Performance Corrected Wheelchair User’s Shoulder Pain Index (PC-WUSPI)^19,20 and muscle strength^13,25; and one trial used the shoulder pain index in WB players (SPI-WB),²⁶ Satisfaction with Life Scale (SWLS),¹⁹ functional tests,¹⁹ radiography,¹³ injury report form,²² and clinical tests²³ (Table 1).

Figure 1.

Flowchart of the articles included in the scoping review.

Table 1.

Characteristics of the included studies.

Author	Year	Study design	Sample size	Mean age (yr)	M/F	Sample extraction	Prevalence/Incidence	Factors/Mechanisms	Treatment/Preventive	Outcome measures
Curtis et al.18	1999	Cross-sectional	46	33	0/46	National women's WB tournament participants	72% (Pain)	Driving posture Excessive wheelchair transfers	–	WUSPI
Ustunkaya et al.19	2007	Cross-sectional	25	29	25/0	Professional sports clubs	44% (Pain)	–	–	WUSPI, PC-WUSPI, SWLS, Functional tests
Yildirim et al.20	2010	Cross-sectional	60	25	–	WB players (Volunteers)	Without trunk control: 60% (Pain) With trunk control: 51% (Pain)	Poor trunk control	–	WUSPI, PC-WUSPI
Akbar et al.13	2015	Cross-sectional	103	49	86/17	SCI patients	75.7% (Rotator cuff tear)	Overuse	–	ROM, Muscle strength, Pain Radiographic
Tsunoda et al.24	2016	Cross-sectional	40	29	19/21	Japanese WB players (National team)	–	Age, Ability class Practice time, Years of experience	–	WUSPI
Wilroy et al.25	2018	Pre-test and post-test model	7	21	5/2	University-based adapted sports	–	–	Shoulder stretch Strengthening exercise
García-Gómez et al.26	2019	Non-RCT	EG: 18 CG: 18	EG: 27 CG: 25	EG: 9/9 CG: 7/11	Elite WB players	–	–	EG: Strengthening, Stretching, Standard recommendation CG: Standard recommendation	ROM, Muscle strength SPI-WB ROM
Pérez-Tejero et al.21	2019	Cross-sectional	17	16–43	–	Elite WB players (WB World Championships)	52.9% (Pain)	–	–	SPI-WB, Clinical tests, ROM
Ylldlrlm et al.27	2019	Cross-sectional	143	32	–	WB players (Volunteers)	–	–	–	Shoulder pain scale
Hollander et al.22	2020	Prospective cohort	132	29	60/72	Elite WB players (WB World Championships)	14% (Injury)	Overuse, Contact	–	Injury report form
Tsunoda et al.23	2021	Cross-sectional	21	32	0/21	Japanese female WB players (National team)	38% (TBGP)	–	–	WUSPI, Clinical tests, ROM

Wheelchair basketball; WB, Wheelchair User’s Shoulder Pain Index; WUSPI, Performance Corrected Wheelchair User’s Shoulder Pain Index; PC-WUSPI, Satisfaction with Life Scale; SWLS, Range of motion; ROM, Spinal Cord Injury; SCI, Randomized controlled trial; RCT, Exercise group; EG, Control group; CG, Shoulder Pain Index in Wheelchair Basketball player; SPI-WB, Tenderness in the bicipital groove point; TBGP.

Regarding the type of disabilities, 179 patients were diagnosed with SCI-induced paraplegia, 53 with polio, 38 with paraplegia, 36 with lower extremity musculoskeletal and neuromuscular disabilities, 18 with amputation, 10 with spina bifida, one with cerebral palsy, and 18 with other disabilities. However, the type of disability was not determined in two studies. Among the 11 studies, seven (63.3%) included elite or professional WB athletes who participated in a world championship or were a member of the national team; conversely, four studies reported on WB athletes who played for recreational purposes. The average weekly training time of the elite or professional group and the recreational group was 9.8 and 10.8 h, respectively. However, studies including recreational athletes define training time as “sports activity time,” which may be different from WB training time. Studies that included elite or professional WB athletes confirmed a direct relationship between the average WB training per week and the prevalence of shoulder pain.

The results of quality assessment are presented in Table 2. Six studies adequately detailed the characteristics^{19,22–24,26,27} and sampling method^{19,21–24,26} of the participants. Four studies^13,20,25,26 clearly explained the inclusion and exclusion criteria. All studies used an appropriate design based on the research questions and measured the key dependent variables. More than half of the studies used reliable and valid measurement tools. Seven studies^{18,21–24,26,27} discussed the external validity of the study results, and six studies^18,22–26 described the limitations.

Table 2.

Quality assessment in included studies.

Author	Year	Participant characteristics	What sampling method is used?	Were inclusion/exclusion criteria stated?	Was the design appropriate to the research question?	Were key dependent variables measured?	Psychometric properties (reliability)	Psychometric properties (validity)	Was the external validity of the results discussed?	Were the limitations of the studies described?
Curtis, et al.18	1999	+ −	+ −	− −	+ +	+ +	+ +	+ +	+ +	+ +
Ustunkaya, et al.19	2007	+ +	+ +	+ −	+ +	+ +	+ −	+ −	− −	− −
Yildirim, et al.20	2010	+ −	+ −	+ +	+ +	+ +	+ +	+ +	− −	+ −
Akbar, et al.13	2015	+ −	+ −	+ +	+ +	+ +	− −	− −	− −	+ −
Tsunoda, et al.24	2016	+ +	+ +	− −	+ +	+ +	+ +	+ +	+ +	+ +
Wilroy, et al.25	2018	+ −	+ −	+ +	+ +	+ +	+ −	+ −	− −	+ +
García-Gómez et al.26	2019	+ +	+ +	+ +	+ +	+ +	+ +	+ +	+ +	+ +
Pérez-Tejero et al.21	2019	+ −	+ +	+ −	+ +	+ +	+ +	+ +	+ +	+ −
Ylldlrlm et al.27	2019	+ +	+ −	− −	+ +	+ +	+ +	+ +	+ +	+ −
Hollander et al.22	2020	+ +	+ +	− −	+ +	+ +	+ +	+ +	+ +	+ +
Tsunoda et al.23	2021	+ +	+ +	− −	+ +	+ +	+ −	+ +	+ +	+ +

+ + =  Yes/Adequately described; + − = Partial / Limited description; − − = Inadequately described /No/Not Stated

The prevalence of shoulder pain in WB athletes varied between the studies. Curtis et al. reported that 33 (72%) of 46 WB athletes had shoulder pain.¹⁸ In addition, Pérez-Tejero et al. reported that 9 (52.9%) of 17 WB athletes had shoulder pain.²¹ Tsunoda et al. reported that 8 (38.1%) of 21 WB players had tenderness in the bicipital groove point (TBGP).²³ Hollander et al. conducted the 2018 WB World Championship (WBWC) injury survey and reported that the percentage of shoulder injuries occurred was 14% of the total.^22.

Ustunkaya et al. investigated shoulder pain in professional WB athletes (n = 25) and non-athletes (n = 23) and found that professional WB athletes had a higher prevalence of shoulder pain than non-athletes.¹⁹ However, there was no significant difference in the intensity of pain during activities of daily living between the two groups. In addition, Akbar et al. investigated the prevalence of rotator cuff tears in individuals with SCI and showed that the sports group had a higher incidence of rotator cuff tears than the non-sports group.¹³ Yildirim et al. showed that 51% of WB athletes with trunk control and 60% of WB athletes without trunk control complained of shoulder pain.^20.

The following factors and mechanisms of shoulder pain were reported: overuse,^13,22 decreased trunk control,²⁰ excessive wheelchair transfers,¹⁸ driving posture (such as arm elevation or upper torso posture),¹⁸ and acute trauma due to contact.²² Additionally, Tsunoda et al. evaluated associations between shoulder pain and age, performance class, practice time, and years of experience and concluded that these factors differed with sex.^24.

Two studies included in this scoping review reported the effects of various interventions to decrease shoulder pain.^25,26 Wilroy et al. recommended a 6-week injury prevention program for WB athletes that included strengthening exercises using bands and shoulder stretching, and reported that the range of internal and external rotations significantly improved after the intervention, but shoulder muscle strength did not.²⁵ García-Gómez et al. performed a 10-week home-based exercise program that included strengthening exercises and stretching exercises for elite WB athletes but reported no significant difference between the patients who performed home-based exercises and the control groups.^26.

Discussion

This scoping review extracted data from 11 studies on shoulder pain in WB athletes. This study found that the prevalence of shoulder pain in WB athletes was between 14%−75%. Additionally, the causes of shoulder pain were likely to be multifactorial; furthermore, previous studies only report on the effectiveness of stretching, and shoulder and scapular muscle strengthening exercises for shoulder pain.

The prevalence of shoulder pain varies widely between studies, which may be attributed to the variety of physical characteristics of the included WB athletes. Half of the study participants had SCI; however, many other disabilities were also included. This approach presents the overall characteristics of WB players; however, the relationship between each disorder and shoulder pain remains unclear. For example, patients with SCI may use a wheelchair for many of their daily activities; in contrast, patients with amputation may opt to not use a wheelchair since they have full control of their other muscles. Therefore, differences in the target population may have affected the results of the studies. Among the 11 studies included in this review, only one focused on WB athletes with SCI.¹³ However, many WB athletes have SCI; therefore, this review highlighted the need for future research in this population.

The WUSPI index is a common tool used to quantify shoulder pain during activities of daily living and has been used in a number of studies.^{18–20,23,24} WB athletes have been shown to complain of shoulder pain during activities of daily living including loading their wheelchairs into a car, pushing up ramps and inclines outdoors, lifting objects down from an overhead shelf, and sleeping. However, different disabilities can affect how a person independently performs activities. Therefore, pain assessment may need to be reported using the PC-WUSPI, which quantifies pain in a performance-modified format. Additionally, self-reported data depend on the honesty and accuracy of the participants; however, their extensive use in the literature may cause limitations. Therefore, future studies should include more objective measures of shoulder function, radiology, and clinical examination to elucidate the pathogenesis of shoulder pain.

This scoping review identified several factors and mechanisms that lead to shoulder pain. These factors include overuse of the upper limbs, increased overhead activity, and participation in sports.^13,22,28 Patients with SCI are encouraged to participate in sports activities; however, this review found that frequent participation in sports can lead to overuse of the upper extremities. Another factor associated with shoulder pain in WB athletes is decreased trunk function,²⁰ which increases dependence on the upper limbs during overhead activities. In addition, WB athletes without trunk control use wheelchairs more often, which causes increased upper limb stress and shoulder pain, compared to those in WB athletes with trunk control. This scoping review primarily found that the development of shoulder pain involves multiple factors and mechanisms; however, the cause of shoulder pain was difficult to identify because most reports were cross-sectional studies.

Treatments and preventive measures are recommended for wheelchair athletes to reduce the risk of injury.²⁹ Among the 11 included studies, two discussed the treatment modalities and preventive measures for WB athletes.^25,26 Strengthening exercises have been shown to reduce the risk of shoulder injuries and lead to positive clinical test outcomes. However, variations in recommended exercise duration and frequency were observed between the studies. In addition, these studies had a small sample size and included varied levels of sports (collegiate to elite level) of WB athletes. Therefore, further research is required to determine the optimal exercise type and duration, the treatment, and preventive measures for WB athletes with different sports levels.

Our scoping review had some limitations. First, this review included only studies written in English. As such, we may have missed important methods that were published in other languages. Additionally, this review searched the existing literature from four databases, but did not include other databases such as Embase, limiting the scope of the search. Finally, the present review was that we summarized lower-evidence-level studies since we failed to find high-evidence-level studies. However, this scoping review designed to identify gaps in the existing literature to help stimulate further research. Therefore, our review may guide future studies on wheelchair basketball athletes.

In conclusion, previous studies on shoulder pain in WB athletes have reported findings on prevalence and incidence, factors and mechanisms, and treatment and preventive measures. Shoulder pain is experienced by many WB players and impedes both training and daily life activities. The factors and mechanisms of shoulder pain were difficult to identify due to the presence of multiple potential factors. Literature on the treatment and preventive measures is limited, and further research is needed to elucidate these issues.

Conflict of interest

No potential conflict of interest was reported by the author(s).