Journal of Orthopaedic & Sports Physical Therapy

1999;29 (4) 3225-231

Shoulder Pain in Female Wheelchair
Basketball Players
Kathleen A. Curtis, Ph D, 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 and 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 Index (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 ( 2 9.1) 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 5 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. 1 Orthop Sports Phys Ther 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 M6 MH29, Fresno, C4 9374W031. E-mail:
kathleencurtis@csufresno.edu
C
ross-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 also 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 t i 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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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-
dr ~me . ~"
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 el e~at i on. ~ Shoulder 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 10 years.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 ndependen~e. ~J~J~ These 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
wheelchair p r o p u l s i ~ n . ~ ~ ~ . ~ ~ We 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 5 10.9
Amputation 4 8.7
Marital status
Single 32 69.5
Married 9 19.6
Divorced 5 10.9
Occupation
Employed 26 57.8
Student 12 26.7
Volunteer 2 4.4
Retired 1 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 with 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 2
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 Isitem, valid, reliable instrument was
used to measure shoulder Each of the 15
J Orthop Sports Phys Ther .Volume 29. Number 4 .April 1999
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TABLE 2. Wheelchair User's Shoulder Pain Index items.
Based on 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 A 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 t i ~el y. ~
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. A 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 t 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 2 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, Y 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 driving 9.8 6.7 0 27
J Orthop Sports Phys Ther-Volume 29.Number 4.April 1999
227
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TABLE 4. Subiect medical history (n = 46).
subjecrs
Responding
"Yes"
Qwsti~n n %
- -
Did you have shoulder pain prior to
wheelchair use?
Have you had shoulder pain during
time you have used a wheelchair?
Have you had shoulder surgery?
Do you currently have shoulder pain?
Haw sought medical attention for a
shoulder problem?
Have you used the following to relieve
shoulder pain:
Ice
Heat
Exercise
Medication
Rest
Has shoulder pain limited you from per-
forming your usual activities during
the past week?
Have vou exwrienced hand or elbow
pain or inbries during the time you
haw used a wheelchair?
Treatment
Only 1 subject reported a previous shoulder sur-
gery. An additional 22 (48%) subjects reported seek-
ing medical attention for their shoulder problems.
The subjects consulted with physicians and physical
therapists most frequently. Ice, rest, exercise, and
heat were the most frequently reported treatments
used for the shoulder problems (Table 4).
WUSPl Scores
Overall, the subjects scored an average perfor-
mance-corrected total WUSPI score of 15.6 + 20.5
points, with the highest intensity of shoulder pain re-
ported while performing household chores, pushing
up ramps or inclines outdoors, lifting objects down
from an overhead shelf, and while sleeping (Table
5). The athletes who reported a history of shoulder
pain since beginning wheelchair use had perfor-
mance-corrected WUSPI scores almost 3 times as
high as those who had not reported a history of
shoulder pain (Figure 1). Further, the group of play-
e n (52%) who reported current shoulder pain
scored an average of 26.3 + 22.6 points, in compari-
son to an average of 3.2 + 6.1 points scored by those
who did not report current pain.
One 36yearald woman player with an amputation
and one 34yeawld woman player with paraplegia
had the highest performancecorrected WUSPI
scores (88.4 and 73.3). Both players were relatively
new to wheelchair use (1 and 4 years, respectively).
They each performed in excess of 35 transfers per
day and reported driving 24 and 12 hours per week,
respectively. The player with paraplegia also spent
over 30 hours per week training for sports.
TABLE 5. Wheelchair User's Shoulder Pain Index (WUSPI) item scores: shoulder pain during functional activities.
sub'@
(n = 46)
Who Performed
Activity Mean SD Minimum Maximum
l-transferring from bed to wheelchair
2--transferring from a wheelchair to a car
3--transferring from a wheelchair to a tub
or shower
+loading your wheelchair into a car
5-pushing your chair for 10 minutes or
more
bpushi ng up ramps or inclines outdoors
7-lifting objects down from an overhead
shelf
8-putting on pants
9-putting on a T-shirt or pull-over
IO-putting on a button down shirt
11-washing your back
12--usual activities at work or school
13--driving
14--performing household chores
1 k l eepi ng
Total WUSPl Score
Performancecorrected
WUSPl Score*
* Performance-corrected WUSPl Score is corrected for subjects who do not perform the activity and therefore did n d mark a pain score on the item.
Performancecorrected WUSPl Score = (Total WUSPl Scordnumber of items performed) x 15.
228 J Orthop Sporu Phy Ther~Volume 290 Number 40April 1999
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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 2
22.1) than did women who did not report shoulder pain since wheelchair
use (6.5 2 11 .a). Women with current shoulder pain had higher PC-WUSPI
scores (26.3 2 22.6) than did women who did not report current shoulder
pain (3.2 2 6.2). Women who reported a history of hand or elbow pain
since wheelchair use had higher PC-WUSPI scores (1 8.0 2 22.4) than did
women who did not report hand or elbow pain since wheelchair use (10.9
2 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 as
those with amputations or lower extremity muscule
skeletal and neuromuscular disorders.
TABLE 6. Correlations of age, years of exposure, and activity lwel with performancecorrected WUSPI score.
Correlation with
Performancd:Orrecfed Coefficient of
WUSPl Score Detennination
Variable Pearson's r (1'1 P Value
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 < .05.
J Onhop Sports Phys Ther.Volume 29. Number 4.April 1999 229
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FIGURE 2. Ambulatory athletes reported higher mean higher performance
corrected mean Wheelchair User Shoulder Pain Index (PC-WUSPI) scores
(20.0 2 25.8) than did full-time wheelchair users (12.8 + 16.5). Athletes
with amputations reported the highest mean PC-WUSPI scores (35.7 2
41.2), followed by athletes with lower extremity musculoskeletal and neu-
romuscular disorders (15.2 2 18.8), athletes with spinal cord injury (14.0
2 18.2), athletes with post-polio paralysis (13.7 2 17.7) and athletes with
spina bifida (7.8 2 8.7).
DISCUSSION
Our results indicate that over 70% of the wheel-
chair basketball players in this study have experi-
enced shoulder pain since beginning wheelchair use.
Further, almost all subjects (over 90%) reported a
history of upper extremity pain or injury involving
the shoulder, elbow, or hand since beginning wheel-
chair use.
In the group we studied, over half of the subjects
reported current pain. Mean WUSPI scores appeared
to differ in subjects who did and did not report cur-
rent pain (Figure l ). Yet, the overall intensity of pain
in the subject pool averaged 15.6 points on a 150-
point scale. For the 24 subjects who reported current
shoulder pain, however, the intensity of shoulder
pain averaged over 8 times higher (at 26.3 points)
than those subjects who did not report current
shoulder pain (at 3.2 points). Shoulder pain may in-
terfere with daily function, specifically during perfor-
mance of household chores, pushing up ramps or in-
clines outdoors, lifting objects down from an over-
head shelf, and while sleeping.
Previous studies have reported that the incidence
of soft tissue injuries in wheelchair users has been re-
lated to hours of exposure or ~a i n i n g . ~. ~ Similarly,
WUSPI scores were shown to be higher with age and
increased years of wheelchair use in a group of para-
lyzed male veterans.' For this relatively young group
of female athletes, neither of these relationships a p
pears to be true. None of the variables of hours of
sports and leisure participation, age, nor years of
wheelchair use were significantly (P > .05) or strong-
ly correlated to WUSPI scores. These results, howev-
er, did show a significant positive relationship
(P < .05) of WUSPI score to 2 other variables that
may increase exposure to shoulder stress.
Hours of driving per week and number of wheel-
chair transfers per day accounted for over 22% of
the variance in performancecorrected WUSPI score.
It is possible that driving posture, specifically, the po-
sitions of arm elevation or upper torso posture, cause
or exacerbate shoulder dysfunction. In addition, the
performance of excessive wheelchair transfers, re-
quire axial loading of the shoulder joint and may
create intra-articular pressures that compress or com-
promise the circulation to soft-tissue structures.' Al-
though these variables seem to be unrelated to specif-
ic sport performance in wheelchair basketball, it
would be wise for athletes and coaches to be aware
that daily activities may predispose an athlete to
shoulder injury or interfere with the healing of a
past injury.
Women with amputations and women with various
permanent lower extremity musculoskeletal and neu-
romuscular disorders are heavily recruited for partici-
pation in wheelchair basketball. The group that we
studied may not fit patterns that were evident in oth-
er groups of full-time wheelchair users, because a p
proximately one-third of the subjects in our study
have disabilities that require wheelchairs for sports
participation, but not necessarily for their daily activi-
ties. The athletes with permanent lower extremity
musculoskeletal and neuromuscular disorders and
amputations have relatively high WUSPI scores de-
spite low average years of wheelchair use (Figure 2).
We must consider the possibility that the stresses of
using a wheelchair may be excessive to these athletes
who are not accustomed to this type of upper ex-
tremity exercise and may result in early shoulder
pain.
A player's role on the team may also determine
the specific shoulder stresses she faces. Athletes with
minimal disabilities are likely to have normal trunk
function and pelvic control. They often assume ball-
handling roles on the team that involve extensive
overhead activity for rebounding, shooting, and pass-
ing. Repetitive stress in these specific actions may be
more likely to cause shoulder impingement. Thus,
the athletes with amputations and lower extremity
musculoskeletal and neuromuscular disorder disor-
ders are not only likely to be unaccustomed to
wheelchair use, they may also assume roles on the
team that put them at additional high risk for chron-
ic subacromial impingement. These 2 factors may
offset the decrease in shoulder stress they experience
when not using a wheelchair for their daily activities.
Clinical Relevance
With such a high percentage of players, and e s
pecially new players, experiencing shoulder pain, it
J Orthop Sports Phy Ther.Volurne 29. Number 4.April 1999
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brings into question how adequately these women
are training and what training habits they routinely
use. Specific preparticipation warm-up and stretch-
ing, and postparticipation cooldown should be en-
couraged before and after all training and competi-
tive sessions. In addition, flexibility and strengthen-
ing exercises should be instituted as part of the con-
ditioning program for all wheelchair basketball
programs to prevent muscle imbalance and impinge-
ment at the s ho~l de r . ~. ~J ~
Limitations of the Study
This survey, by cross-sectional design, relied on
self-report data at a single point in time. There may
be a sampling bias because only players who attend-
ed the National Women's Wheelchair Basketball
Tournament were surveyed and there may be self-se-
lection among athletes who consented to participate
and returned the questionnaire. By using this design,
we have no data to report or predict the trend of
shoulder pain over time. Also, associations between
variables and shoulder pain are correlational and a
cause and effect relationship cannot be presumed.
Directions for Future Study
A longitudinal study in this population is indicated
and future research should assess the effectiveness of
interventions that influence the onset and progres
sion of shoulder dysfunction in female wheelchair
basketball players. It would be particularly interesting
to follow athletes with amputations and lower ex-
tremity musculoskeletal and neuromuscular disorders
to identify why the intensity of their pain seems to be
so great with relatively few years of competitive histe
ry. Also, this study assessed only the presence of
shoulder pain, not the etiology or specific lesion of
players with pain. Future research should differenti-
ate between articular and soft tissue origins of shoul-
der pain.
CONCLUSION
Shoulder and upper extremity pain affected 41 of
46 female wheelchair basketball players. Shoulder
pain was weakly related to activity levels, such as
transfers performed per day and in hours spent driv-
ing per week. There was no relationship between
shoulder pain and either age or years of wheelchair
use. Prevention of pain and chronic disability in ath-
letes who use wheelchairs should be addressed by
F"-!
coaches, players, and health care professionals.
ACKNOWLEDGMENTS
i
The authors thank the California State University, i m i
Fresno, Physical Therapy Department; the Women's ' m i
Division, National Wheelchair Basketball Association,
p!
and the 1997 National Women's Wheelchair Basket-
[ A ?
ball Tournament Organizing Committee for their
I f i ,
t I.-:
support in conducting this study. The authors also
thank ChrisTina Buettell for her assistance with data
1. A
i m !
transcription and Kianna Modir-Fatemi for her assis
W !
tance with manuscript preparation and revisions.
[ 0 '
, A ;
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