ORIGINAL�ARTICLE ABSTRACT Objective: To determine the prevalence of shoulder pain in spinal cord injury patient using manual wheelchairs in Khyber Pakhtunkhwa. Study Design: Cross sectional. st Place and Duration of Study: The study was carried out at Paraplegic Center Peshawar from 1 January 2014 to th 30 June 2014. Materials and Methods: A cross sectional survey using convenience sampling method was used to determine the prevalence of shoulder pain in spinal cord injury patients using manual wheelchair at Paraplegic Center Hayatabad Peshawar. A total of one hundred and fifty traumatic paraplegic and tetraplegic patients using manual wheelchair post two weeks were included in this study. Wheelchair user shoulder pain index (WUSPI) was used as data collection tool. Descriptive statistic was applied. Frequencies and percentages were calculated for identifying the responses of patients to different questions, for level of injury, and identifying the prevalence. Results: A total of one hundred and fifty (150) manual wheelchair user tetraplegic and paraplegic spinal cord injury patients were included in this study. Among them 84% were male while 16% were female. The prevalence of shoulder pain was 34.7% while performing different activities in manual wheelchair users. From patient's responses, it was declared that shoulder pain was most common while pushing on inclined surfaces and ramps, pushing the wheelchair for 10 minutes or more, sleeping on the shoulder and transferring from bed into wheelchair. While at rest 89.3% of the subjects were free of pain. Conclusion: Most of the traumatic spinal cord injury (SCI) manual wheelchair users (MWUs) complain of shoulder pain during the course of their rehabilitation program. Shoulder pain restricts most important activities of daily living like pushing wheelchair on inclined surfaces, ramps and transferring from bed to wheelchair and wheelchair to bed. Key Words: Manual Wheelchair User, Spinal Cord Injury, Shoulder Pain, Wheelchair User Shoulder Pain Index. than 3 segments below the neurological level of injury while the Incomplete injury means some preservation of sensory and/or motor function more than 3 segments below the neurological level of 2 injury. Spinal Cord Injury (SCI) is a devastating event that brings significant changes in life of the victims as well as their family. Presently there is no SCI registry at national level in Pakistan. Therefore, there is no accurate estimate of the number of individuals who suffer from SCI in Pakistan every year. The research on epidemiology of traumatic SCI in Pakistan is very limited. About 650-750 spinal cord 3 injuries occurred in October 2005 in Pakistan. Globally around 90 million individuals are suffering from spinal cord injury (SCI). In developed countries SCI incidence ranges from 1 to 5 persons per 4 100,000. The most common causes of spinal cord injury are automobile accidents (31.5%), fall from height (25.3%), gunshot injury (10.4%),motor cycle 5 accidents (6.8%) and diving (4.7%). The Manual Introduction Any kind of neural disturbance in the spinal cord whether from trauma or disease is called spinal cord 1 injury. According to the Standards for Neurological Classification published by the American Spinal Injury, the term complete injury means no preservation of motor and/or sensory function more The Prevalence of Shoulder Pain in Spinal Cord Injury Patients Using Manual Wheelchair in KPK (Khyber Pakhtunkhwa) 1 2 3 Rafiullah , Sayed Zulfiqar Ali Shah , Sajida Mazhar Correspondence: Dr. Sayed Zulfiqar Ali Shah Department of Rehabilitation Sciences Rehman College of Rehabilitation Sciences Rehman Medical Institute, Peshawar E-mail: Zulfiqar_kmu18@yahoo.com 1 Department of Physical Therapy Rafsan Neuro Rehabilitation Center Saddar Peshawar 2 Department of Rehabilitation Sciences Rehman College of Rehabilitation Sciences Rehman Medical Institute, Peshawar 3 Department of Physical medicine and Rehabilitation Sciences Institute of Physical Medicine And Rehabilitation Sciences Khyber Medical University, Peshawar Funding Source: NIL; Conflict of Interest: NIL Received: Oct 27, 2016; Revised: Dec 13, 2016 Accepted: Feb 12, 2017 Shoulder Pain in Manual Wheel Chair PatientsJIIMC 2017 Vol. 12, No.2 101 the prevalence and study different aspects of shoulder pain experienced by spinal cord injury patients in Khyber Pakhtunkhwa (KPK), using manual wheelchairs. Materials and Methods A cross sectional survey was designed to identify the prevalence of shoulder pain in manual wheelchair users. The study was carried out at Paraplegic Center st th Peshawar from 1 January 2014 to 30 June 2014. A total of 150 subjects both male and female with traumatic SCI using MWC were included in this study. It was mandatory that subject have completed two weeks rehabilitation training in paraplegic center Peshawar and Rafsan neuro rehab center Peshawar and currently. Data was collected using WUSPI with the help of follow up program team of paraplegic center Peshawar and some subject were directly interviewed in Rafsan neuro rehab center Peshawar and paraplegic center Peshawar. WUSPI is a 15-items questioner specifically designed for independent MWCUs scored from zero to ten with zero representing no interference of pain with daily activity and ten represents complete interference. Inclusion criteria was independent Manual wheelchair users, patients of both gender with traumatic spinal cord injury, C5 and below level Quadriplegics subjects, age 18 -59 years, completed at least 2 weeks rehabilitation in an inpatient center. Subjects with any of the following were excluded from the study: paraplegic and Quadriplegics not using MWC, progressive diseases Paraplegics, above C5 level Tetraplegic, patients with age range below18 years and above 60 years, , PWC (power wheel chair) user subjects, subject having shoulder pain from a history of fall on affected shoulder after SCI, subject experiencing referral pain from any other part of the body, subjects that are dependent for wheel chair propulsion and transferring. The WUSPI was used for data collection which is a standard valid questioner. The covering letter was send along with the questioner to explain purpose of the study to the subjects. Willing participants filled consent form and questionnaire. SPSS version 20 was used for data analysis. Descriptive statistic was applied. Frequencies and percentages were calculated for identifying the wheelchair ((MWC) is a potential enabling 6 technology for mobility impaired people. The MWC is a source of mobility and support to the body. It facilitate activities of daily living (ADL), self-care and 7 recreation activities. In United States, around 1.7 million people were using wheelchair in 2000 in which 1.5million were MWUs (manual wheelchair 8 users). The lifelong dependency of SCI patient on MWC for their ADLs causes repetitive loading of shoulder joint and consequently results in shoulder 9 pain. The upper extremity repetitive use, high forces a n d a w k w a r d p o s t u r e l e a d s t o s h o u l d e r 10 impingement in MWCUs. Also the increase weight, high seat position and prolong disability may lead to 4 shoulder pain in these patients. Shoulder pain in MWCUs may result from shoulder impingement (75%), rotator cup tears (65%), aseptic humeral h e a d n e c r o s i s ( 2 2 % ) , t e n d i n i t i s a n d 11 bursitis. Epidemiological studies have revealed that shoulder pain is common in MWC users and its 12 prevalence ranges from more than 32–78%. Two third of MWUs complain of shoulder pain after five 13 years of injury. After 20 years of injury almost all of 9 MWCUs complain of shoulder pain. A study has reported that shoulder pain prevalence in tetraplegic is 59%and 42% in paraplegic MWCUs SCI 14 patient. Shoulder pain in manual wheelchair users 15 result into decrease quality of life. Initially MWC users ADLs may not be affected so much but later on it may result early fatigue, low level of endurance, lower work potential and reduced cardiopulmonary 16 endurance. The Wheelchair Users Shoulder Pain Index (WUSPI) is a 15 item tool for assessing shoulder pain while at rest and during activity. The pain intensity is measured through a 10cm line with zero (0) representing no pain and ten (10) representing the worse pain experienced on the basis of the past 17 week activities. Spinal cord injury patients exclusively rely on upper limb for weight bearing activities like transfer and wheelchair propulsion, so it is necessary to keep them aware of proper wheelchair use, shoulder loading and shoulder complication in order to keep 18 them functional in society. Shoulder pain in spinal cord injury patients in Pakistan is under reported and up to author's knowledge no research has been found on this topic in Pakistan. This study was designed to determine JIIMC 2017 Vol. 12, No.2 102 Shoulder Pain in Manual Wheel Chair Patients Discussion Postspinal Cord Injury (SCI) life expectancy of the patient has improved as a result of advancement in medical care and followed up in specialized unit. The SCI patient are compelled to go through repetitive weight bearing activity through their upper limb(UL) joints as a compensation for paralyzed lower limb (LL) and trunk muscle while performing different activity of daily life (ADL), as a consequence, they develop shoulder joint pain at some stage of their life. Very less number of patients (10.7 %) reported shoulder pain at rest while 34.7% reported shoulder pain with wheelchair related activities. Most of the participants (41.3%) reported shoulder pain while pushing wheelchair on inclined surfaces and ramps. This study results revealed that 89.3% of the SCI patients have no pain while it rests. A similar results were obtained from a study conducted it the United Kingdom by Dorsett (2001) showed that among SCI responses of patients to different questions, for level of injury, and identifying the prevalence. Results The wheelchair user shoulder pain index (WUSPI) was used for data collection. A total of one hundred and fifty (150) manual wheelchair user tetraplegic and paraplegic spinal cord injury patients were included in this study. Among them 84% were male while 16% were female. The age limit was from 19 to 58 years. Among all 86.7% of the subjects were manual wheelchair users from one to five (1-5) years while the 13.3% were using wheelchair from the past five to twenty years. Among the total recruited patients there were 64% with thoracic, 28% with lumber and 7% with cervical level of spinal cord injury patients. The shoulder pain noticed was as following. About 10.7 % of the subject reported shoulder pain even at rest while 89.3% of the subjects were free of shoulder pain while at rest. The prevalence of shoulder pain with wheelchair related activity was 34.7%. The shoulder pain was most common (41.3 %.) while pushing on inclined surfaces and ramps. Among all 20% of the participants reported mild shoulder pain when pushing their wheelchair for ten minutes or more. Some of the patients (24%) reported that they feel pain while washing their back while 17.3% reported that they feel pain during transferring from bed into wheelchair. The prevalence of shoulder pain while sleeping was 18.7%.The subjects were asked to mark their pain level on a 10cm line of visual analog scale (VAS) according to their pain intensity while performing activities. The severity of the pain on VAS was graded as“no pain, worse pain ever experienced and activity not performed”. Table I: Rehabilita�on dura�on of the study popula�on (n= 150) Table II: Level of injury of the study popula�on (n= 150) Table III: Pain at rest and on ac�vity JIIMC 2017 Vol. 12, No.2 103 Shoulder Pain in Manual Wheel Chair Patients wheelchair users 80% did not reported shoulder pain 19 while at rest. Shoulder pain should be treated at priority it may later restrict patient's ADLs. Conclusion This study concludes that the prevalence of activity related shoulder pain was high than pain at rest as many participants were having pain during activity. This study also concludes that most of the manual wheelchair users with spinal cord injury experience shoulder pain in activities which put more load on their shoulder joint and rotator cuff muscles, like profiling on inclined surfaces and transferring from bed to wheelchair. Most of the patient experience shoulder pain in their later years of rehabilitation. Recommendations This study recommends that the proper wheelchair training and upon experience of shoulder pain; proper treatment should be taken to facilitate further wheelchair use and combat immobility. Patients should be taught not put abnormal weights on the shoulder and always ask for assistance for activities that demands high forces. REFERENCES 1. Maynard FM, Bracken MB, Creasey G, Ditunno JF Jr, Donovan WH, Ducker TB, et al. 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