Introduction
thletes who mainly use their upper limbs in sports usually complain of shoulder disorders and pain [1, 2]. Inman et al. were the first to measure scapulohumeral rhythm by radiography and suggested a 2:1 ratio for glenohumeral elevation and scapulothoracic upward rotation [3]. Some of the literature suggests the 2:1 ratio is not consistent across an entire arc of shoulder elevation and that variability in this ratio may increase when considering the scapulohumeral rhythm exhibited by shoulder injured subjects [5, 4]. Some previous studies have suggested that scapula muscle dysfunction can lead to abnormal alignment and upper limb dysfunction [6, 7]. One of the scapula’s abnormal problems is its low rotation syndrome, which causes the scapula to fall, drain, and tilt [8, 9]. Previous research in people who use wheelchairs examined their scapulae condition in activities such as translocation and weight loss [10, 11, 12]. According to these studies, changes in the scapula directions and movements and arm during these activities reduce the space under the acromion, which increases the risk of injury [10, 11, 12]. Transmissions in people who use wheelchairs are performed with compensatory changes in the scapula kinematics, maintaining space under the acromion during activity [11]. 
The previous scapula kinematics results of wheelchair drivers are mainly concluded from studies that have examined the scapula movements unilaterally (right or left) [13, 14, 15]. But wheelchair driving is a bilateral activity that requires coordination of both upper limbs, and therefore its symmetry cannot be ignored [16]. Although previous data show scapula asymmetry when driving in a wheelchair [16, 17, 18, 19, 20], we still need to research scapula movements bilaterally (right and left). Wheelchair players are at risk of overworked shoulder injuries due to the frequent use of their upper limbs to drive wheelchairs. Repeated wheelchair mechanisms cause repetitive scapular protrusions that can lead to postural changes, stabilizing muscle weakness, and anterior muscle stiffness. Compensatory muscle imbalances may be due to prolonged wheelchair use or defects in the rotator cuff and scapula stabilizers’ strength training programs. This condition can lead to musculoskeletal injuries in athletes who require different movement patterns (such as swimming, throwing, or racket sports) [21, 22]. However, it is unknown whether activation has a protective effect on the musculoskeletal system [23]. Previous studies in this field have investigated the scapulohumeral rhythm in injured people and healthy athletes. However, no studies have been performed on wheelchair basketball players, and the effect of exercise interventions on the scapula in these people has not been studied. Thus, we aimed to investigate the indexes of scapular upward rotation and scapulohumeral rhythm in wheelchair basketball players and see the exercise program’s results based on scapula stability on these indexes.
Materials and Methods 
The research method is quasi-experimental. According to the research conditions, 24 wheelchair basketball players with spinal cord injuries participated in this study. First, 8 players from each sports class (sports class 1 to 1.5, sports class 2 to 2.5, and sports class 3 to 4.5) were selected. Then, four people from each sports class were randomly assigned to the control or experimental group (12 control and 12 experimental). Thus, an equal number of three sports classes were present in each group. Wheelchair basketball players were professional players in the Mashhad City League, Iran. The participants were classified according to the IWBF classification and the relevant sports classification from the Veterans and Disabled Sports Federation of the Islamic Republic of Iran (IRISFD), both of which are required for people with physical disabilities to participate in competitions. Individuals with a history of shoulder surgery, injury, and pain were excluded from the study 6 months before the test. Two digital inclinometers were used to measure the motion of the arm and scapula range at rest position and 45°, 90°, and 135° shoulder abduction angles at the scapula scaption surface. The study’s final results to measure the scapular upward rotation in resting positions (ICC=0.89) and angles 45° (ICC=0.88), 90° (ICC=0.89), and 135° (ICC=0.82), arm abduction had internal reliability between tests.
The exercise group performed a corrective exercise program based on scapula stability for eight weeks to strengthen and stretch the scapula stabilizing muscles. In the first session, all subjects received about one hour of training on how to do the exercises, and also each subject was given written instructions and a picture of how to do the exercises for guidance at home. The training program included five days a week, daily stretching exercises, and three days of strength training. Each training session consisted of a maximum of 60 minutes (10 minutes of warm-up, 10 minutes of stretching and range of movement after warm-up or cooling, and a maximum of 30 minutes of strength and postural exercises based on scapula stability and 10 minutes of cooling). In each training session, the examiner and a bodybuilding instructor were present to guide the subjects. This exercise program has been prepared using Gym exercises for people with spinal cord injury provided by Harborview Medical Center and following The American College of Sports Medicine (ACSM). guidelines for these people [24, 25]. The independent t-test, Aanalysis of Variance (ANOVA), and Analysis of Covariance (ANCOVA) were used to analyze the data. The significance level was determined at P≤0.05 in all tests.
Results
Table 1 presents the demographic information of the subjects. 


Tables 2 and 4 show the scapular upward rotation and the scapulohumeral rhythm before and after the exercise program in the control and exercise groups.




ANCOVA showed a significant difference between the control and exercise groups in the scapular upward rotation in resting positions and 45°, 90°, and 135° shoulder abduction angles after exercise in preferred and non-preferred hands. The results showed a significant improvement in scapulohumeral rhythm ratio after non-preferred hand training at 90° and 135° shoulder abduction angles. The results showed no significant asymmetry between the preferred and non-preferred shoulder in the scapular upward rotation (Figure 1) at different shoulder angles, but there was a significant difference in the scapulohumeral rhythm ratio at the 45° angle of shoulder abduction in the preferred and non-preferred shoulder (Table 3). 

Based on the variance test results analysis, there was a significant difference in the scapular upward rotation and scapulohumeral rhythm in different sports classes at resting position, 45°, 90°, and 135° shoulder abduction (Table 5). 


Discussion and Conclusion 
This study aimed to investigate the indexes of scapular upward rotation and scapulohumeral rhythm in wheelchair basketball players and measure the effectiveness of an exercise program based on scapula stability on these indexes.
The results showed no significant asymmetry in the scapular upward rotation in different degrees of shoulder abduction between the preferred and non-preferred shoulders in these athletes. At a 45-degree shoulder abduction angle, the scapulohumeral rhythm ratio in the preferred shoulder was lower than that in the non-preferred shoulder. The scapula in the preferred shoulder of athletes with lower sports classes (2 to 2.5 and 3 to 4.5) had a less low rotation at resting position and more upward rotation at 45°, 90°, and 135° shoulder abduction angles.
The ratio of scapulohumeral rhythm in athletes with different sports classes was not significantly different. The scapula’s further upward rotation was observed as the arm elevation increased in the frontal plane, which corresponds to the scapula’s role in overhead activities to optimize performance. At resting position, the lower rotation was observed some more. But at different degrees of shoulder abduction, less upward rotation was observed in the scapula. Almost like the scapulohumeral rhythm, the share of the scapular upward rotation in the entire shoulder elevation arch is different, consistent with previous reports [26, 27]. Some kinematic studies have shown differences in the scapula position and movements on both sides [28, 29, 30, 31, 32, 33], while others suggest symmetry in the scapula kinematics in the preferred and non-preferred shoulder [27, 34]. 
Barry et al. reported internal rotation, upward rotation, and anterior scapular tilt during wheelchair driving [35]. Martin et al. showed wheelchair tennis players had a more posterior tilt in the scapula during arm elevation and lowering it to the preferred than non-preferred position [36]. The scapula in these individuals had more upward rotation to the preferred side during the arm’s elevation on the scapula plate than those with shoulder involvement [36, 37, 38, 39]. It can be concluded that asymmetry, especially an anterior tilt pattern or the internal scapula rotation, is associated with shoulder pathology or its susceptibility. It seems that one of the reasons for the anterior glenohumeral instability in athletes is throwing, which can make them prone to shear stress and damage to the capsule anterior structure and labrum. 
The results showed no significant difference between the preferred and non-preferred shoulders of wheelchair basketball players in the scapula resting position. However, the scapula had lower rotation in the preferred shoulder than the non-preferred shoulder. These results are probably due to adaptations to the particular position used in the musculoskeletal system, such as muscle length imbalances in the scapulothoracic muscles due to repeated but different frequency and movement patterns in the preferred and non-preferred shoulder [6, 29, 40]. It was also observed the mean amount of the scapular upward rotation at resting position, 45°, 90°, and 135° angles of arm abduction in the preferred shoulder of wheelchair basketball athletes with different sports classes was significantly different, which may be due to muscle imbalance. 
People with lower exercise classes have better muscle control over the trunk, and the trunk-scapular muscles provide more scapular stability during arm elevation. This study showed that a corrective exercise program based on scapula stability improved scapular upward rotation in wheelchair basketball players. After the training program, the scapular downward rotation decreased in dominant and non-dominant shoulder in the resting position (effect size respectively, 0.33, 0.52) and scapular upward rotation had a significant increase in 45º and 135º of shoulder abduction in dominant side (effect size respectively, 0.3, 0.22) and had a significant increase in 45º, 90º and 135º of shoulder abduction in non-dominant side (effect size respectively, 0.52, 0.25, 0.47). Although no significant improvement was observed in the scapulohumeral rhythm ratio in the preferred shoulder, it improved in the non-preferred shoulder at 90° and 135° angles of arm abduction (effect size, 0.27, 0.28, respectively). 
The scapula muscle strengthening was associated with a significant increase in its upward rotation angle and a significant decrease in scapulohumeral rhythm. According to this study results, the scapula direction, as described by Kendall et al. [41], deviated somewhat from the normal state. Therefore, a corrective exercise program based on scapula stability can maintain and restore the scapula’s normal position and possibly repair and improve the standard muscle length in the upper rotator scapula muscles.
Overall, this study showed that wheelchair basketball players have some asymmetry in the upward scapular rotation and the ratio of the scapulohumeral rhythm between the preferred and non-preferred shoulder. It is due to specific adaptations to imposed demands [42] and muscle imbalances caused by spinal cord injury. This study showed that the selected exercise program could be effective in correcting the scapula direction and movements during arm elevation in wheelchair basketball players. This finding is consistent with the Shaman and Caldwell results, which examined the impact of scapula exercise programs [43, 44].
The study’s limitations were the small sample size and its non-blindness according to the research conditions. It is suggested that similar studies on scapula disorders be performed in other groups of athletes with wheelchairs, especially spinal cord injuries (such as tennis, archery, etc.) and women.
The study results supported the effectiveness of the scapula stability-based correction exercising program in improving scapula movements in wheelchair basketball players. The scapula has an essential role in shoulder movements, whose postural and movement disorders can cause secondary problems such as shoulder pain, shoulder entrapment syndrome, and limited motion range. So, physicians and trainers devote part of their training program to scapula stabilizers. Despite our results, more research and follow-up are needed to prepare an effective exercise therapy program for wheelchair athletes and identify its long-term effects in preventing injury and determining its benefits in wheelchair athletes, especially wheelchair basketball players.

Ethical Considerations
Compliance with ethical guidelines
Necessary coordination was arranged with the head of the welfare department of Mashhad City and Imam Khomeini and Shahid Fayyaz Bakhsh rehabilitation centers. The proposal was approved by the Research Commission of the University of Guilan. The participants were informed of the purpose of the research and its implementation stages. A written consent has been obtained from the subjects. They were also assured about the confidentiality of their information and were free to leave the study whenever they wished, and if desired, the research results would be available to them. The Helsinki Convention was also observed.

Funding
This article was extracted from the PhD. dissertation of the first authorat Department of Sports Injuries & Corrective Exercise, School of Physical Education and Sport Sciences, University of Guilan, Rasht.

Authors' contributions
Conceptualization, methodology, data collection, and data analysis: Abdollah Maarouf, Hassan Daneshmandi, Ali Asghar Norasteh; Writing – original draf: Hassan Daneshmandi, Ali Asghar Norasteh and Ahmad Ebrahimi Atri.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
We appreciate the wheelchair basketball players with disabilities of Imam Khomeini and Shahid Fayyazbakhsh Rehabilitation Centers in Mashhad City, who participated in this study.


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