i

ASSOCIATION OF PHYSICAL ACTIVITY WITH HEALTH-

RELATED QUALITY OF LIFE AMONG WHEELCHAIR BOUND
POPULATION OF LAHORE

Research Supervisor

Dr. Maida Mushtaq

Head Supervisor
Prof. Dr. Muhammad Salman Bashir

Submitted By

Name ID
Mateh Ur Rehman F2017241199
Reffat Nizam F2017241137
Naheed Shoukat F2017241045
Luqman Ali F2017241016
Syed Muhammad Aun F2017241069

DOCTOR OF PHYSIOTHERAPY

Session 2017-2023

School of Health Sciences

University of Management and Technology

 ii

DEDICATION

We, hereby declare that all the information in this thesis is the result of our concerted

efforts and our original work. This research work, to the best of our knowledge and

belief, reproduces no material previously published or written, or that has been

accepted for the award of any other degree or diploma, except where due

acknowledgement has been made in the text.

 iii

ACKNOWLEDGEMENT

As a matter of first importance, I want to say thanks to Allah for giving us a chance to

fulfil our dream and ability to do this thesis project. After that we are appreciative to

people who supported us ethically to get what we need as well.

We would like to thank our supervisor Dr. Maida Mushtaq who had confidence in us

and supported us every time we need. They are source of inspiration for us throughout

our work. We are everlastingly grateful to Dr. Maida Mushtaq for their steady help,

consolation, and tolerance through this procedure. We can never payback the

activities and enable them, the accomplished they shared by disclosing to us that our

theory is on track or not and revealing to us the thoughts. We must say without them it

would be impossible for us to display our thesis project.

Finally, we would like to thank the honourable, respectful and the most important

people in our life our Parents who have done so much for us. Without them, we are

nothing and we were unable to do anything we have done. They supported us through

every thick and thin, without them it was impossible for us to complete our work.

To wrap things up, most profound much gratitude goes to all individuals who

participated in making this project genuine.

 4

DECLARATION

We declare that the research project “ASSOCIATION OF PHYSICAL ACTIVITY

WITH HEALTH-RELATED QUALITY OF LIFE AMONG WHEELCHAIR BOUND
POPULATION OF LAHORE” is based on our own work carried out during our study
under the supervision of Dr. Maida Mushtaq. We assert that statements made,
and conclusions drawn are an outcome of our research work. We further certify
that the work contained in the report is original and has been done by us under the
general supervision of our supervisor and co-supervisor.

The work has not been submitted to any other institution for any other degree in this
university. We have followed the guidelines provided by the university in writing the
report.

Whenever we have used materials (data, theoretical analysis, and text) from other
sources, we have given due credit to them in the text of the report and have given
their details in the references.

Researcher’s Signatures
Mateh Ur Rehman
Reffat Nizam
Naheed Shoukat
Luqman Ali
Syed Muhammad Aun
 5

APPROVAL CERTIFICATE

Research Project entitled “ASSOCIATION OF PHYSICAL ACTIVITY WITH HEALTH-

RELATED QUALITY OF LIFE AMONG WHEELCHAIR BOUND POPULATION OF

LAHORE” is accepted by the faculty of School of Health Sciences, University of

Management and Technology, Lahore, in partial fulfilment of the requirement for the

degree Doctor of Physiotherapy (DPT).

\
Supervisor

Dr. Maida Mushtaq

Co-Head Supervisor
Dr. Rabia Jawa
(Chairperson of Department of Physical Therapy & Rehabilitations)

Head Supervisor (Dean SHS)

Prof. Dr. Muhammad Salman Bashir

(Dean, School of Health Sciences)

 6

LIST OF TABLES

Table: 1 Mean, Min, and Max of Physiological Domain …………………...26

Table: 2 Cumulative Percentage of Physical Activity……………………...……27

Table: 3 Frequency of Psychological Domain………………………...…………30

Table: 4 Percentage of Psychological domains…………………….………….31,32

Table: 5 Personal Relationship of Statistics….……………………….………….33

Table: 6 Support from family and friends…………………………………....….33

Table: 7 Overall Social Health……………………………………....……...…33,34

Table:8 Frequency Of physical Environment……………………………….…….35

Table:9 Frequency of Leisure Activities……...………………………………….36

Table:10 Cumulative Score of Environment…………………………………...36,37

Table:10 Cumulative Score of All-Domains……………………………………...38

Table:11 Reliability of Quality of Life…………………………………….…….38

 7

LIST OF Figures

Figure 1: Mean Of Age Respondent………………………………………………….24

Figure 2: Gender of Participants……………………………………………………...24
Figure 3: Ability to perform daily activity………………………………………...….25.
Figure 4: Satisfaction with sleep………………………………………….………......26
Figure 5: Physical Activity of participants……………………………………...…….27
Figure 6: Satisfaction with yourself……………………………………………….......28
Figure 7: Negative feeling of participants……………………………………………...29
Figure 8: Overall Psychological…………………………………………………..…...29
Figure 9: Personal relationship of respondent ……………………………………...….32
Figure 10: Support from friend…………………………………………………,,,,…...32
Figure 11: Overall social health of participants…………………………………...……32
Figure 12: Physical Environment……………………………………………………….34
Figure 13: Leisure Activities…………………………………………………………….35
Figure 14: Cumulative Environmental domains…………………………………..…….35
Figure 15: Quality of life of all domains………………………..……………………….37
 8

Table of contents

Contents

DEDICATION......................................................................................................2
ACKNOWLEDGEMENT.....................................................................................3
DECLARATION...................................................................................................4
APPROVAL CERTIFICATE................................................................................5
…
ABSTRACT.........................................................................................................10
CHAPTER 1.........................................................................................................11
INTRODUCTION................................................................................................11
1.1 Background.....................................................................................................11
1.2 Problem Statement..........................................................................................14
1.3 Significance: ....................................................................................................15
1.4 Objectives: .......................................................................................................15
1.5 Hypothesis: ......................................................................................................15
CHAPTER 2 .........................................................................................................16
LITERATURE REVIEW ....................................................................................16
CHAPTER 3 .........................................................................................................22
METHODOLOGY................................................................................................22
3.1 Study design ....................................................................................................22
..
3.2 Sample/ participants.........................................................................................22
3.3 Data collection technique.................................................................................22
3.4 Analysis technique...........................................................................................23
3.5 Ethical consideration.......................................................................................23
CHAPTER 4 .........................................................................................................24
RESULTS..............................................................................................................24

CHAPTER 5..........................................................................................................39

5.1 Discussion........................................................................................................39
5.2 Limitation.........................................................................................................40
CHAPTER 6 ..........................................................................................................41
6.1 Conclusion: ......................................................................................................41
6.2 Recommendation: ............................................................................................41
Appendices............................................... ............................................................42
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WHO QOL-BRIEF Questionnaire……………………………………………………………….… …...42

REFERENCES .....................................................................................................46
Permission Letter………………………………………………………………………………………………49
PLAGIRIASM REPORT …………………………………………………………………….…………………………….50
 10

Abstract

Background

Physical activity gives a person overall sense of well-being and good quality of life. Likewise,

any restriction in performing physical activity will lead to different kind of disabilities.

Worldwide prevalence of disabilities is 15% and in Pakistan it ranges up to 12 % of total

population. Lack of awareness, accessibility of aids due to several reasons makes the condition

worse. A good strategy to Bridge all the Gaps should be taken under consideration.

Objectives

The objective of this study is to find the effects of physical activity on the physical,

psychological, social, and environmental domains of Quality of life in different age group

peoples restricted on wheelchair at Rising sun school, step-ahead school, Jinnah Hospital,

General Hospital and Spring-field school in Lahore.

Methods

Pre-certified WHO QOL-BRIEF questionnaire was used to collect data from 100 participants

with their consent and research was conducted after due permission of the authorities. Data was

analysed by using SPSS 26.0.

Results

The consisted study includes 60% male and 40% female. Physical activity domain showed minimum

6% and maximum 88% on scale. Psychological domain showed minimum value of 6% and maximum

of 94%. Social domain showed 0% and maximum 81% on scale. Lastly the environment had minimum

19% and 88% maximum on scale. Values varies as per age, level of participation and life experiences.

Scores were high in those who were physically active i.e., engaged in wheelchair sports, was motivated

in life to achieve goals, and had supportive family and friends or vice versa.
 11

Chapter # 1

Introduction

1.1: Background

People with disability globally ranges up to 16% and in Pakistan’s Population

this ratio is up to 12%. Disability is basically any impairment which could be related to body
or mind of person leading to limitation in performing activities and restrictions in participation.
Physical activity is the most important factors affecting the quality of life of individuals among
healthy living peoples. Physical activity refers to all the bodily activities that involves skeletal
muscles and requires energy. It includes almost all the activities that we perform to do a task
and all the activities of daily livings. Physical activity is directly related to health of an
individual and have many benefits in individual’s life, like healthy weight reduces risk of
chronic disease such as heart disease and diabetes. Not just physical benefits but it also has
very good impacts on a person’s mental health. As Health-related quality of life is all about
one’s perception of his health status on Quality of life which includes domains of not just
physical activity but also psychological and social functioning. So, we can say that greater the
physical activity of person greater will be his Health-related Quality of life. (2,3)

In today’s time almost all the young adults are more prone to different conditions due to
their physical in-activity. And the peoples who are bound to wheel-chair due to any of the
following reason i.e., Spinal cord injury, congenital condition (spina bifida, cerebral palsy etc),
motor vehicle accident leading them to spend rest of their lives on wheelchairs are even at
higher risk as compared to normal youth. Wheelchair bound person face many problems in
daily life and other co-curricular activities like engaging in friendship. Not just the person but
the family members lives are also affected as parents also faces many problems majorly
concerned about financial reasons, Social-Discrimination and barriers faced in the health
system itself. Individual, Physical activity directly relate to quality of life and over wellbeing
of that person. Not only this but lack of physical activity will lead to many secondary conditions
i.e., obesity, type 2 diabetes, coronary heart conditions affecting HRQOL negatively. To collect
information about a person’s activities is very important as it will give insight on whether a
person is physically active or have sedentary lifestyle and secondly the intensity of physical
activity sheds light on aerobic fitness so it’s also very important. It’s an interesting way to
collect data by combining different activities, while performing activities of daily living as it
will show people HRQOL in wheelchair are affected negatively as compared to normally
 12

developing peers because wheelchair bound are less physically active and more sedentary in
lifestyle. (4,5,)

Almost 15 % of the global population have disability under the age of 14 and even in Pakistan
this range varies to around 12 % of total population affection their life not just by physical
means but also socially and ultimately psychologically. Wheelchair bound have better HRQOL
as compared to non-Wheelchair users who are physically disabled. As wheelchair improves
their mobility and benefiting them psychosocially and in developmental stages. However, there
is limited understanding of these aids of mobility and how they affect HRQOL. It’s important
to spread awareness about how wheelchair offers independent mobility which will have
benefits in psychosocial development, increases functional mobility movement. Person, who
are wheelchair-bound should be taught appropriate wheelchair interventions to help them
obtain maximum benefits to increase their HRQOL. (5)

Life is not same or just for all of us , just like the physically disabled person or adults as they
have to face a lot of challenges in their lives and our study focuses on better understanding of
this population, how their HRQOL is affected by the environment, physical activities they
perform, their mobility and their very own perception about their lives, and being physically
disabled is not just a challenge for them but also for the closed ones like family and relatives
and how their lives are affected too. It’s not as easy as it looks life being physically disabled or
we can say even more challenging than it looks like as every stage of life is a tough challenge
for you when you are physically disabled. Peoples judge you; you have difficulty in making
friends, being discriminated while participating in leisure activities. To overcome these issues,
we must spread awareness to take care of all the related taboos. We must bridge the gap
between normally developing peers and wheelchair bound or other physically disabled by
disability awareness training and other affective methods.

Above mentioned challenges are even more in Pakistan as compared to U.K disability ratio
varies from 6.2 % to 12 % and according to some latest studies total physical disability ration
is around 19% of total population. And most of the physically challenged are illiterate and lack
access to aids like aids of mobility to help them increase their HRQOL. Even though they have
the right of freedom of speech but the taboo in our society makes the situation worse for them.
Educating them and providing them with awareness helps them a lot. They should be aware for
a healthy lifestyle; an essential component is physical activity, and it also includes wheelchair-
bound individuals. Wheelchair-bound faces many challenges when it comes to physical
 13

activity, but regular exercise and movement can have positive impacts on their overall health
and well-being. Wheelchair-bound individuals can engage in many kinds of physical activities,
including wheelchair basketball, wheelchair racing, and hand cycling. These activities not only
provide physical benefits but can also help improve psychological development and provide a
sense of community and social support. (7)

Another major reason especially related to physical and social challenges are Neuromuscular
disorders. It’s an umbrella term for group of diseases including Duchenne Muscular dystrophy.
It affects peripheral nervous system leading to progressive muscular weakness. Progressive
muscle weakness leads to many co-morbidities and lack of ambulation compromises physical
health. Due to weakness in Individuals HRQOL is very poor, and it goes up to comparable with
the normally developing peers.

Spinal cord injuries are among the major causes leading to wheelchair for ambulation as an
injury to spinal cord affects lower extremities directly leading to poor mobility and ultimately
an individual uses wheelchair to raise his QOL. Spinal cord is part of CNS, and it carries
message from and toward brain and injury to this will cause poor functional activities and
ultimately decreasing HRQOL. The affects vary according to severity of injury that could be
Complete or Partial/Incomplete. In complete injury person face complete motor and sensory
loss while in incomplete or partial injury means partial loss of motor and sensory functions.
The affected area can be determined according to area where spinal cord injury happened. (14)

Wheelchair-bound individuals experiences lower HRQoL as compared to normal peers. This

is because of many factors, including mobility limitation, increased dependence, socially
isolating themselves, and other health complications like higher risk of developing pressure
ulcers. However, an important point to note is that not all wheelchair users will have same
HRQoL. For example, some experiences a higher HRQoL who have a supportive family and a
good social network as compared to someone who has socially isolated themselves. Additional
factors like age, gender, and reason of individual's wheelchair use can also affect their HRQoL.
For improving HRQoL of wheelchair-bound individuals, it's important to emphasize on both
physical, psychological, and social factors, including making mobility aids accessible and other
equipment like ramps and wheelchair lifts, also providing access to social support programs.
Moreover, in this population HRQOL can also be improved by promoting healthy habits and
physical activity. (16)
 14

In wheelchair users to maintain and improve their overall health engaging in regular physical
activities can be helpful, including cardiovascular health, muscle strength, and bone density.
Secondary conditions like pressure sores, muscle atrophy, and osteoporosis can be prevented.
Wheelchair users can engage in different types of physical activities according to their
individual interests and abilities. Some examples include Wheelchair sports: wheelchair users
enjoy participating in sports such as basketball, rugby, tennis. Resistance training: helps users
to maintain their muscle mass and bone density, also improves their ADLs performance.
Cardiovascular exercise: it includes wheelchair aerobics, hand cycling, or wheelchair dancing
in maintaining and improving cardiovascular fitness and endurance. Yoga or stretching it
improves flexibility and range of motion of individual. (17)

It's important for wheelchair users to work with a healthcare professional or physical therapist
to develop an individualized exercise plan that considers their specific needs and abilities. They
can also provide guidance on proper technique and equipment, as well as ways to prevent injury
or exacerbating existing medical conditions.

1.2: Problem statement

This study aimed to evaluate the “Association of physical activity with health-related quality
of life among wheelchair bound Population of Lahore”. According to different studies
conducted in Malaysia, England, America and some Asian countries, any kind of disability will
affect all the domain of health-related quality of life whether its physical social psychological
or environmental and these disabilities could be congenital, traumatic could be related to
injuries to spinal cord. This study is going to check how physical activity help them raise their
Quality of life in different age groups from different disabilities. We have collected data
through WHO QOL-BRIEF questionnaire from people of different age-group from different
Centres of Special Need. Our study is conducted in Pakistan as all the other research are done
in foreign countries and very less work is done in Pakistan. Moreover, the basic goal is to
choose this topic is to spread the awareness about this topic is very necessary especially for
illiterate peoples so they can understand that they can live life with better Quality of life.
 15

1.3: Significance

This study will help to find out the health-related Quality of life among wheelchair bound
restricted person with congenital abnormalities or other conditions ultimately leading to use
wheelchair for aid. As it’s necessary to adopt appropriate strategies to increase the level of
physical activity among person to help them raise their Quality of life taking in consideration
of all its domain of physical, psychological, environmental, and social domains.

1.4: Objectives

• To address the wheelchair bound population in Pakistan to improve quality of life and
quality of care for them.
• To Know the Quality of Life and wellbeing among wheelchair bound.
• To find the Development of a mobility-related quality of life that is significant for
wheelchair bound.
• To find the difference between time spent in sedentary lifestyle and being physically
active in wheelchair using.
• To know HRQoL defined by Childs with mobility impairment and by their parents too,
in relation to wheelchair use.
• To know the social disability model, which states that main challenges faced by
wheelchair bound are due to the way society treats them and not because of their
impairment.

1.5: Hypothesis:

➢ ALTERNATIVE HYPOTHESIS (Ha):

There is association between physical activity with health-related quality of life among
wheelchair bound.
NULL HYPOTHESIS (Ho):
There is a no association between physical activity with health-related quality of life
among wheelchair bound.
 16

CHAPTER 2

Literature Review

2.1: Health Related Quality of Life (HRQoL) in CP.

Power et al. (2019) conducted a study in Bangladesh to determine the health-related quality of

life and mental health of person with cerebral palsy in rural community. They identified that

person with CP had poorer feelings with functioning level that covered domains of mental

health, Friendship, what will happen later in life, physical activity, and feelings about having

CP from both self-reported and proxy reported groups. They concluded that information given

by the person with CP were more prone to have low level of HRQoL and mental health status

than peers without disability. (10)

Longo et al. 2020 organized the study in which Person with Cerebral Palsy (CP) Talked About

Their Experiences on Barriers and Facilitators to Participation in Leisure Activities. According

to this study, they concluded that person faced many problems with the way they were

perceived and judged by society and by themselves is quite problematic. They wanted to

change their disabled parts if they could, so that they could enjoy life like other normal person

and also so that nobody bullies them for how they look, and how could it be modified to

enhance their participation in leisure activities. And how to become a confident, self-

determined and better version of themselves to serve the community with the way they are.

(20)

This study is conducted by Blasco et al. 2023 in which they studied factors affecting quality of

life in person with cerebral palsy. Result of their study said that the visual perception functions

and executive functions, parental stress and motor functional status are major constituents

affecting CP person’s quality of life. (36)

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2.2: Effects of Neuromuscular disease on HRQOL

Gocheva et al. (2019), conducted research in University of Basel to examine the

Neuromuscular disorder outcome in post-polio syndrome and Duchene Muscular Dystrophy.

They conducted cross sectional study that assessed Health related quality of life and motor

function in ambulant and non-ambulant DMD. They concluded that 56% of the patients were

psychosocially impaired. PedsQL scores for person with DMD were lower than those for

healthy person for physical and psychosocial HRQOL. They further stated that more studies

and more improvement is needed to work on neuromuscular disorders. (17)

2.3: Effect of congenital or chronic disorder on QOL of Wheelchair bound person

Bolemen et al. 2019, supervised the study on the physical activity in wheelchair using person

with spina bifida. Physical activity and exercise are directly related to quality of life and well-

being among all human beings. Lack of physical activity in person with spina bifida makes

them more prone to co morbidities and other complications due to more time spent on

wheelchair. They assessed the several physical activities and their intensities in manual

wheelchair users. They pointed that they person with spina bifida (SB) who used manual

wheelchair were less physically active and more sedentary than peers without disability. Also,

this study stated that their physical activity during school days is better as compared to weekend

days. (02)

Thong et al. 2019 leaded a study on Health-related quality of life in person with spina bifida in

University of Putra Malaysia. According to their findings, they concluded that person with

spina bifida scored low in parkin QoL questionnaire due to several contributing factors that

included neurogenic bowel and bladder, shunt, non-ambulator and most importantly being a

single child of the family. (08)

 18

Gowran et al. 2022 conducted study in Ireland to look into skills training and education in

wheelchair bound person with spina bifida. Focus of their study is to develop and evaluate

impact of training on performance of skills in wheelchair bound person and to explore parents’

perspectives about their person’s participation to learn skills. Availability of resources,

communication gap and limited knowledge restricted parents from supporting their child. Short

training programs were more impactful positively for parents and person for awareness and

relationships for skill development. (37)

Martins et al. 2019 conducted the study in which they explored decreased respiratory

performance in wheelchair bound person with spina bifida. Wheelchair bound person in spina

bifida are less physically active due to which they have alteration in normal functioning of

structures i.e., muscular weakness and less endurance of respiratory muscles due to which their

vital capacity and the maximal voluntary ventilation (MVV) decreases leading to poor

respiratory performance. If they indulge in physical activity or exercise and ADLs, due to lack

of proper ventilation it will compromise peripheral muscles and will lead to impairment. (38)

Cortés et al.2022 organised a study on Osteogenesis imperfecta affecting QoL of people’s lives

chronically with pain. They concluded that in this condition pain increases day by day with

activities and causes a toll on QoL in regards of physical as well as mental health. They further

stated that cognition of pain bears more favourable outcomes than learning coping strategies.

(A.35)

Oliveira et al. 2022 supervised the study on adults with juvenile idiopathic arthritis to check

the effect of their physical activity and its effects on health-related quality of life. They finalised

the point that Health Related QoL is directly related with physical activity and family support

lays an important role in accomplishing the desired goals so they should participate too to

support the adults with JIA. (26)

 19

2.4: Effect of disability on psychosocial wellness of wheelchair bound

A study conducted in 2020 by Knight et al. at Factors Affecting Out of-School Activities of

the Participation of Physically Disabled Person. Study is concluded by emphasizing there is

gap between users and facilitator and the need to provision improvement through disability

awareness training to increase their psychosocial wellness. To enhance out-of-school activities

person require the same focus and attention to meet their social needs to encourage their

wellbeing. (05)

Kyrku et al. 2018 did research on health-related quality of life of the family who have a child

with disability. According to this study Disabled person’s parents encounter many challenges

and problems as compared to normally developing peers, not only this but they also have to

raise not only child’s QOL but also family quality of life (FQOL. As families faces problems

regarding behavioural difficulties and finding right supporting strategies. Health related family

quality of life HRFQOL is affected directly by disability of child, but to enhance family quality

of life it is important to fulfil the needs of child. (12)

2.5: Role of Motivation to engage in physical exercise in manual wheelchair users.

Caruana et al. 2020 conducted study on Paraplegic Manual Wheelchair person about

Motivation to Physical Exercise. They found that main motive to engage Paraplegic Manual

Wheelchair person in physical activity is ill-health avoidance and moreover motivation is

related directly to perform specific physical activity. To promote motivation for exercise health

care providers, need to work on behavioural change strategies for well-being. (13)

Study that is conducted by Brag et al. 2019 on sports and physical activities for wheelchair

bound person. The main objective of this study is to do research on this topic because of

research gap. Lack of research on this topic makes it difficult to evaluate the participants and
 20

get outcomes. More-over they emphasized on additional research for better outcomes in future.

(15)

Mason et al. 2018 did work on wheelchair bound person to support physical activity and playful

interactive systems in them. They concluded that social aspects played an important role either

for motivating physical activity or for demotivation in participants also some were affected

negatively because of their abled bodies leading to non-participation, meanwhile they had

empathy for other wheel-chair users. Time cost and environmental barriers were also

significant barriers for engaging in Physical activity in wheelchair bound person. (18)

2.6: Health-related quality of life in wheelchair users due to spinal cord injury:

A study conducted by Szeliga et al.2022 checked the relationship between physical activity

level and functional status in spinal cord injured patients. It summarized that people with spinal

cord injury are recommended rugby training because of its positive mental and physical effects.

(27)

Willig et al. 2020 conducted the study on chronic paraplegic patients using manual wheelchair

to check their effectiveness in upper body exercise programs. They concluded that , performing

two exercises on patients i.e, aerobic and resistant exercises that mostly implemented for upper

body regimes. They found that both exercises have positive effect in term of QoL and Physical

well-being. (24)

Bochkezanian et al.2022 conducted the study to find the association of quality of life in wheel-

chair sports participants and in physically disabled participants. They finalised on the fact that

participants in wheelchair sports had positive relation with QoL. They further concluded that

that regular physical activity affects individuals QoL positively results were much greater in

participants that participate in wheelchair sports. (28)

 21

Chapter 3

Methods

3.1. Study Design:

It’s a Cross sectional study type as we collected data from different persons in a certain point

of time.

3.2. Sample:

We collected data through convenient sampling from tertiary hospital, schools, and centres of

especially abled. The sample size is 100 and the included participants were wheelchair bound

due to any of the congenital or acquired condition of age group 25-50, including both male and

female. The excluded individuals were the peoples with traumatic injuries (amputation),

cognitively impaired, wheelchair bound peoples with serial casting more than 3 months. The

sample size is calculated by using Epitool by adding the study specifications in software.

3.3. Data Collection Techniques:

WHO QOL-BRIEF questionnaire is approved by research supervisors and whole committee to

collect the data for the study. Questionnaire included the domains of health-related quality of

life which are physical, psychological, social, and environmental. Peoples were asked about

their physical activity in association with their quality of life and how different aspects of their

life were affected by being on wheelchair. Questionnaire also included data regarding the social

and psychological factors of their life and including environmental factors all these latter

domains have negative effects overall, only some positive numbers were recorded with

increased physical activity domain and rest of the domains were dependent of family and

friend’s support. Data is collected by physically visiting the hospital, schools, and centres of

especially abled.
 22

3.4. Statistical procedures/ analysis techniques:

Statistical analysis of the data is done on (SPSS) Statistical Package for Social Sciences to get

mean, standard deviation and frequency and for the graphical representation of the data.

3.5. Ethical Considerations:

A letter of approval for data collection for study is attached in the beginning of the study. As

per research ethics in consideration data is collected by in all domains of HRQOL in wheelchair

bound with informed consent.

 23

Chapter 4

Results

4.1 Mean and Standard Deviation of Biography of Selected Population

The Research is carried out at different places in Lahore. The places included Jinnah hospital,

General hospital, Rising Sun institute, Step ahead and Springfield institute. Data is collected

about 100 confirmed participants that were wheelchair bound. Out of these 60 are male and 40

are female. The mostly affected participants (44%) with age range of 25-55.

AGE OF RESPONDANT
50
42
40 35
PERCENT

30 23
20

10

0
25-35 35-45 45-55
AGE OF RESPONDANT

Fig1: Mean of Age of Respondent

Gender

40%
Female
60% Male

Fig 2: Gender of the Participants

 24

4.2 Physical Activity in Wheelchair bound.

The first domain of our questionnaire is physical activity that categorizes into further seven

questions. Whereas 1 show very poor and 5 show very good physical activity on the scale. The

Question 3 and 4 were negatively framed and we recoded them into positively framed. And all

question transformed into 0-100 on scale in which 0 shows minimum and 100 shows maximum

Physical activity. Among 100 Participants, 37% showed that physical pain prevents from doing

physical activity, 40% were taking a medicine to perform their daily activity. When Questioned

about their sleep 42% were confused, 28% were dissatisfied, 29% are dissatisfied about their

capacity for doing physical activity. The Physical activity domain showed minimum value of

8 that is 6% on scale and maximum is 32 that’s 88% on scale and range 24 on scale showed

63% of the transformed data on scale of WHO.

How satisifed with your abililty to perform your daily

living activities?
40 36
34
35
30
25
Percent

20 18

15
10 7
5
5
0
Very Dissatified Dissatified Neither Satisfied Very satsified
How satisifed with your abililty to perform your daily living activities?

Fig3: Ability to Perform Daily activity.

 25

How satisified are you with your sleep?

3% 7%
20%
28%

42%

Very Dissatified Dissatified Neither Satisfied Very satsified

Fig4 Satisfaction with Sleep

Frequencies Table

Statistics
Physical

N Valid 100
Missing 0
Mean 19.8500
Std. Error of Mean .42744
Median 19.0000
Mode 17.00a
Std. Deviation 4.27437
Variance 18.270
Range 24.00
Minimum 8.00
Maximum 32.00
Sum 1985.00
a. Multiple modes exist. The smallest value is shown

Table 1 Mean, Minimum and Maximum of Physical Domain

 26

Descriptive Statistics

Frequency Percent Valid Percent Cumulative Percent

Valid 8.00 1 1.0 1.0 1.0

9.00 1 1.0 1.0 2.0
11.00 1 1.0 1.0 3.0
13.00 1 1.0 1.0 4.0
14.00 4 4.0 4.0 8.0
15.00 7 7.0 7.0 15.0
16.00 5 5.0 5.0 20.0
17.00 12 12.0 12.0 32.0
18.00 8 8.0 8.0 40.0
19.00 12 12.0 12.0 52.0
20.00 3 3.0 3.0 55.0
21.00 6 6.0 6.0 61.0
22.00 11 11.0 11.0 72.0
23.00 8 8.0 8.0 80.0
24.00 8 8.0 8.0 88.0
25.00 3 3.0 3.0 91.0
26.00 2 2.0 2.0 93.0
27.00 4 4.0 4.0 97.0
28.00 2 2.0 2.0 99.0
32.00 1 1.0 1.0 100.0
Total 100 100.0 100.0

Table 2 Physical activity Cumulative Percentages

 27

Physical1

12 12
11
Percent

8 8 8
7
6
5
4 4
3 3
1 1 1 1 2 2 1

8 9 11 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 32
Physical1

Fig5: Physical activity of Participants

4.2 Psychological Health of Wheelchair Bound Participants

In psychological domain six question were included. The Q26 which is about negatively

feeling that is negatively framed and converted into positively framed. According to statistics,

35% showed dissatisfied with themselves, 38% showed they were moderately concentrated

on their life to do any activity. When questioned about their satisfaction with their selves 35%

are dissatisfied and 57% were suffering through mood, despair, anxiety, and depression. If we

see overall psychological health of wheelchair bound participants, it is fair. The statistical

data showed minimum value was 7 and maximum was 28 and mostly range was lying

between 21 that was 63% of total score.

 28

How satisfied with yourself?

40
35
35
30
31
25
Percent

20 23
15
10
5 9
2
0
Very Dissatified Dissatified Neither Satisfied Very satsified
How satisfied with yourself?

Fig6: Satisfaction with yourself

How often do you have negative feeling such

as anxiety and depression?
Always Never
13% 2% Seldom
19%

Very Often
30%

Quite often
36%

Never Seldom Quite often Very Often Always

Fig7 Negative Feeling of Participants

 29

Fig8 Overall Psychological Health

Frequency Table
Statistics

How often do
you have
negative
To what Are you able feeling such
How much Extent do How well are to accept as anxiety
you enjoy day your life to be you able to your bodily How satisfied and
in life? meaningful concentrate? appearance? with yourself? depression?
N Valid 100 100 100 100 100 100

Missing 0 0 0 0 0 0
Mean 2.9700 2.7400 2.6900 3.0200 3.3300
2.7200
 30

Median 3.0000 3.0000 3.0000 3.0000 3.0000 3.0000

Mode 2.00a 3.00 2.00 3.00 2.00 3.00

Std. Deviation 1.01956 1.03103 .82505 1.03553 1.01484 .99549

Range 4.00 4.00 3.00 4.00 4.00 4.00

Minimum 1.00 1.00 1.00 1.00 1.00 1.00

Maximum 5.00 5.00 4.00 5.00 5.00 5.00

a. Multiple modes exist. The smallest value is shown

Table 3 Frequencies of psychological Domains

Pshycological2
Frequency Percent Valid Percent Cumulative
Percent
Valid 7.00 1 1.0 1.0 1.0
8.00 1 1.0 1.0 2.0
9.00 1 1.0 1.0 3.0
10.00 1 1.0 1.0 4.0
11.00 4 4.0 4.0 8.0
12.00 6 6.0 6.0 14.0
13.00 10 10.0 10.0 24.0
14.00 4 4.0 4.0 28.0
15.00 7 7.0 7.0 35.0
16.00 11 11.0 11.0 46.0
17.00 9 9.0 9.0 55.0
18.00 11 11.0 11.0 66.0
19.00 11 11.0 11.0 77.0
20.00 7 7.0 7.0 84.0
21.00 4 4.0 4.0 88.0
22.00 6 6.0 6.0 94.0
23.00 2 2.0 2.0 96.0
24.00 2 2.0 2.0 98.0
26.00 1 1.0 1.0 99.0
28.00 1 1.0 1.0 100.0
Total 100 100.0 100.0

Table4 Percentages of Psychological Domains

 31

4.3 Social Status of Wheelchair restricted Population

The social domain contains three variables that’s personal relationship, marital relation, and

relation with friends. According to scale by WHO the minimum score is 3 that shows low level

social status and maximum level is 15 to display high level social health of wheelchair bound

population. According to statistical relationship, the personal relationship of patient is 41% and

65% are in between satisfaction or dissatisfaction. Those who got support from friend and

family members were 28% satisfied. The 34% participants selected never because they were

not married and 33% were dissatisfied. If we conclude the overall social health it’s in the range

of 10 that is 56% of computed scale.

HOW SATISFIED WITH YOUR

PERSONAL RELATIONSHIP?
30 27
24 24
25
FREQUENCY

20
15 13
11
10
5 1
0
.00 Very Dissatified Neither Satisfied Very satsified
Dissatified
HOW SATISFIED WITH YOUR PERSONAL RELATIONSHIP?

Fig9 Personal Relationship of Respondent

 32

How satisfied are you with the support

you get from your friends?

7% 9%
Very Dissatified
28% 25% Dissatified
Neither

31% Satisfied
Very satsified

Fig10 Support from Friends

Social Domain
20
18 19
16
14 15
Frequency

12 14
10
8 10
9
6 8
7
4 6
5
2 4
3
0
3 4 5 6 7 8 9 10 11 12 13
Social3

Fig11 Overall Social Health of Participants

How satisfied with your personal relationship?

Cumulative
Frequency Percent Valid Percent Percent
Valid .00 1 1.0 1.0 1.0
Very Dissatisfied 13 13.0 13.0 14.0
Dissatisfied 27 27.0 27.0 41.0
Neither 24 24.0 24.0 65.0
Satisfied 24 24.0 24.0 89.0
Very satisfied 11 11.0 11.0 100.0
Total 100 100.0 100.0
Table5 Personal Relationship statistics
 33

How satisfied are you with the support you get from your
friends?
Cumulative
Frequency Percent Valid Percent Percent
Valid Very 9 9.0 9.0 9.0
Dissatisfied
dissatisfied 25 25.0 25.0 34.0
Neither 31 31.0 31.0 65.0
Satisfied 28 28.0 28.0 93.0
Very satisfied 7 7.0 7.0 100.0
Total 100 100.0 100.0

Table6 Support from Family and Friends

Social Statistics
Cumulative
Frequency Percent Valid Percent Percent
Valid 3.00 3 3.0 3.0 3.0
4.00 10 10.0 10.0 13.0
5.00 6 6.0 6.0 19.0
6.00 19 19.0 19.0 38.0
7.00 15 15.0 15.0 53.0
8.00 14 14.0 14.0 67.0
9.00 8 8.0 8.0 75.0
10.00 9 9.0 9.0 84.0
11.00 7 7.0 7.0 91.0

12.00 4 4.0 4.0 95.0

13.00 5 5.0 5.0 100.0
Total 100 100.0 100.0

Table7 Overall Social Health

4.4: Environmental Factors effect on wheelchair bound

Total number of variables this domain has are 8 related to safety and life, physical environment,

financial needs and environments related to activities of daily living including leisure activities

too. According to our results mostly peoples fell moderate category and then in very much
 34

secondly in response of how healthy is your physical environment which ranged 33% and 34%

respectively. 31% were satisfied with their living conditions. 40% were those who had very

little opportunity to engage in leisure activities. According to WHO transform scale their score was

lying in 56% which is considered in overall fair environment category.

How healthy is your physical environment?

40
35
30
25
Percent

20
15
10
5
0
Not at all A little A moderate Very Much Extremely
amount
How healthy is your physical environment?

Fig12 Physical Environment

TO WHAT EXTENT DO YOU HAVE THE

OPPORUNITY FOR LEISURE ACTIVITES?
Completely Not at all
Mostly 5% 10%
14%

A little
Moderately 40%
31%

Fig13 Leisure Activities

 35

11

9
8 8
Percent

7
6
5 5
4 4 4 4 4
3 3 3 3
1 1 1 2 2 1 1

13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
Environmental

Fig14 Cumulative Environmental Domain

How healthy is your physical environment?

Cumulative
Frequency Percent Valid Percent Percent
Valid Not at all 5 5.0 5.0 5.0
A little 20 20.0 20.0 25.0
A moderate amount 33 33.0 33.0 58.0
Very Much 34 34.0 34.0 92.0
Extremely 8 8.0 8.0 100.0
Total 100 100.0 100.0
Table8 Frequency of Physical Environment

To what extent do you have the opportunity for leisure activities?

Cumulative
Frequency Percent Valid Percent Percent
Valid Not at all 10 10.0 10.0 10.0
A little 40 40.0 40.0 50.0
Moderately 31 31.0 31.0 81.0
Mostly 14 14.0 14.0 95.0
Completely 5 5.0 5.0 100.0
Total 100 100.0 100.0

Table9 Frequency of leisure activities

 36

Environmental4
Cumulative
Frequency Percent Valid Percent Percent
Valid 13.00 1 1.0 1.0 1.0
14.00 3 3.0 3.0 4.0
15.00 1 1.0 1.0 5.0
16.00 1 1.0 1.0 6.0
17.00 2 2.0 2.0 8.0
18.00 4 4.0 4.0 12.0
19.00 8 8.0 8.0 20.0
20.00 4 4.0 4.0 24.0
21.00 5 5.0 5.0 29.0
22.00 7 7.0 7.0 36.0
23.00 8 8.0 8.0 44.0
24.00 5 5.0 5.0 49.0
25.00 6 6.0 6.0 55.0
26.00 3 3.0 3.0 58.0
27.00 9 9.0 9.0 67.0
28.00 4 4.0 4.0 71.0
29.00 11 11.0 11.0 82.0
30.00 4 4.0 4.0 86.0
31.00 3 3.0 3.0 89.0
32.00 4 4.0 4.0 93.0
33.00 2 2.0 2.0 95.0
34.00 1 1.0 1.0 96.0
35.00 1 1.0 1.0 97.0
36.00 3 3.0 3.0 100.0
Total 100 100.0 100.0

Table10 Cumulative score of Environmental Domain

4.5: Overall QOL and Reliability in wheelchair bound

We computed over QOL, and it majorly depended on psychological and social domains. As per Crohn’s

alpha that we used to check the reliability of QOL according to which 0.00 to 0.69 means poor QOL.

0.70-0.79 goes for fair, 0.80-0.89 means good QOL, 0.90-0.99 shows excellent QOL. According to the
 37

result of data collected in our study our Crohn’s alpha value is 0.79 that points fair QOL in overall QOL

and reliability in wheelchair bound population.

OverallQOL

6 6
5 5
Percent

4 4 4 4
3 3 3 3
222 2 222 22 2 2 2 2 22 2
1111111 11 1 1 1 11 111 1

35 43 45 51 53 55 57 59 61 63 65 67 69 71 73 75 77 79 81 83 85 89 96
OverallQOL

Fig15 QOL of All domains

Statistics
PHYSICAL PSYCHOLOGICAL Social ENVIRONMENT
N Valid 100 100 100 100
Missing 0 0 0 0
Mean 46.4500 45.3700 38.2200 54.2400
Median 44.0000 44.0000 31.0000 56.0000
Std. Deviation 15.10794 16.45112 21.71886 16.99443
Skewness -.098 .046 .268 -.073
Std. Error of .241 .241 .241 .241
Skewness
Kurtosis .131 .106 -.680 -.626
Std. Error of .478 .478 .478 .478
Kurtosis
Minimum 6.00 6.00 .00 19.00
Maximum 88.00 94.00 81.00 88.00

Table 11 Cumulative score of All domains

 38

CRONCH’S ALPHA

Reliability Statistics
Cronbach's Alpha
Based on
Cronbach's Alpha Standardized Items N of Items
.793 .814 4

Table12 Reliability of Quality of life

 39

Chapter # 05

5.1. Discussion

5.1.1. Association in QOL and wheel-chair sports participation

Bochkezanian et al., 2022 conducted a study on “Association of QOL in wheelchair sports

Participants”. Conclusion of the study stated that the QOL of wheelchair sports participants

was higher than non-participants pointing a positive relationship. This study also associated

with previous studies agreed on the same fact that the individual’s overall QOL is directly

related to activity he engages in. And wheelchair sports participants had highest scores.

Collectively. This study results stated that there was a positive association in QOL and wheel-

chair sports participation in wheelchair bound population.

5.1.2. Psychological QOL in Wheelchair users.

Travlos et al, 2018 conducted the study which stated, as wheelchair users have low physical

QOL. The mental wellbeing of wheelchair bound appeared comparable to normal developing

peers. But the study was limited with poor collection of data like participants details, their

age, gender and physical abilities and lack of strategies and appropriate measures. Overall, it

stated that psychological well-being if left non-considered will lead to poor transition from

adolescence to adulthood.

5.1.3. Out of school activities participation by wheelchair restricted children

Knight et al, 2020 conducted a study on “Participation of wheelchair bound children in out of

school activities”. The findings of the study showed that there is need of improvement in the
 40

provision of co-ordinated approach strategy and awareness training in wheelchair bound by the

authorities to raise the QOL by bridging the gap between carers and population being served. TO raise

QOL and well-being in children it’s important to take this point in consideration to make sure their out

of school activities are enhanced.

5.2. Limitations

This study is applicable to evaluate the association of physical activity with health-related

quality of life in wheelchair bound population in Punjab specially in Lahore and associated

cities. It is not applicable to wheelchair bound due to amputation and non-wheelchair users,

patients had difficulty and mostly showed confusion while giving consent to fill the

Performa. This study is not applicable to people with psychological illness affection their

QOL, any not to the patients belonging to lower Punjab and not in the cities other than

mentioned, patients below than the mentioned age and pregnant females.
 41

Chapter # 06

6.1. Conclusion

As per results of this study the conclusion is that the health-related Quality of life is affected

by all the domains of physical psychological social and environmental and to raise the quality

of life we need to take care of all the domains specially the social and psychological and the

relationship of physical activity with HRQOL is positive, increased physical activity

increases QOL. According to this study the peoples in Lahore city of Pakistan who are

wheelchair bound gave data through WHO QOL-BREIF questionnaire have fair quality of

life as Crohn’s alpha 0.79 value computed after result. Even though this study had some

limitations, it emphasized on the importance of further research needed on the association of

physical activity with HRQOL in wheelchair bound population. Research’s directions in

future should be in more deep investigation of Physical activity with HRQOL in wheelchair

bound population and influence of different domains of QOL in it.

6.2. Suggestion

As we mentioned in our study the majorly affecting domain are domain of psychological and

social so the Awareness about the Disabilities, wheelchair ambulation, Wheelchair aiding

strategies etc all matters the most in raising the QOL in wheelchair restricted persons. More-

over a study should be case- controlled so that we can find exact effect of physical activity in

QOL in wheelchair bound population.

 42

Appendices:

Questionnaire:

Questionnaire

Topic: Association between physical activity with health-related quality of life among
wheelchair bound population

Name: -------------------, Age: --------------------, Gender: Male Female

Location: ----------------------, Weight: ----------------, Height: ------------------,

Occupation: Laborer , Employee Self business others

THE WHOQOL-BREF
General Health

Neither
Very Very
Poor poor
Poor Good good
nor good

How would you rate your quality

1 1 2 3 4 5
of life?

Neither
Very satisfied
Dissatisfie Very
Dissatisfie nor Satisfied
d satisfied
d dissatisfie
d

How satisfied are you with your

2 1 2 3 4 5
health?
 43

A
Very
Not at all A little moderate Extremely
much
amount

7 How well are you able to concentrate? 1 2 3 4 5

How safe do you feel in your daily

8 1 2 3 4 5
life?

How healthy is your physical

9 1 2 3 4 5
environment?

The following questions ask about how much you have experienced certain things in the last
two weeks.

A An
Not at Very
A Little moderate extreme
All much
amount amount

To what extent do you feel that

3 (physical) pain prevents you from 1 2 3 4 5
doing what you need to do?

How much do you need any

medical
4 1 2 3 4 5
treatment to function in your daily
life?

5 How much do you enjoy life? 1 2 3 4 5

To what extent do you feel your

6 1 2 3 4 5
life to be meaningful?

The following questions ask about how completely you experience or were able to do certain
things in the last two weeks.

Completel
Not at all A little Moderately Mostly
y

Do you have enough energy for

10 everyday 1 2 3 4 5
life?
 44

Are you able to accept your bodily

11 1 2 3 4 5
appearance?

Have you enough money to meet

12 1 2 3 4 5
your needs?

How available to you is the

13 information that you need in your 1 2 3 4 5
day-to-day life?

To what extent do you have the

14 1 2 3 4 5
opportunity for leisure activities?

15
How well are you able to get around? 1 2 3 4 5

The following questions ask you to say how good or satisfied you have felt about various
aspects of your life over the last two weeks.

Very Neither
Dissatisfie Very
dissatisfie satisfied nor Satisfied
d satisfied
d dissatisfied

How satisfied are you with your

16 1 2 3 4 5
sleep?

How satisfied are you with your

17 ability to perform your daily living 1 2 3 4 5
activities?

How satisfied are you with your

18 1 2 3 4 5
capacity for work?

19 How satisfied are you with yourself? 1 2 3 4 5

How satisfied are you with your

20 1 2 3 4 5
personal relationships?

How satisfied are you with your sex

21 1 2 3 4 5
life?
 45

How satisfied are you with the

22 1 2 3 4 5
support you get from your friends?

How satisfied are you with the

23 1 2 3 4 5
conditions of your living place?

How satisfied are you with your

24 1 2 3 4 5
access to health services?

How satisfied are you with your

25 1 2 3 4 5
transport?

The following question refers to how often you have felt or experienced certain things in the
last two weeks.

Quite
Never Seldom Very often Always
often

How often do you have negative

26 feelings such as blue mood, despair, 1 2 3 4 5
anxiety, depression?

Did someone help you to fill out this

form?..............................................................................................................
How long did it take to fill this form
out?.................................................................................................................

Do you have any comments about the assessment?

......................................................................................................................................................
..................
......................................................................................................................................................
..........................................
THANK YOU FOR YOUR HELP
 46

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50