Lateral epicondylitis in tennis players VS badminton players

Thesis Submitted to
Azra Naheed Medical College
Superior university, Lahore

In Partial fulfillment of the

Requirement for the Degree of

Doctor of Physical Therapy

Tamoor Hassan

Roll No.13164

Session: 2012 -2017

Registration No DPHY 13164

Azra Naheed Medical College

Superior University, Lahore

1
Approved By:

_________________________ ________________________
Dr Hafiz Sheraz Arshad Prof. Research Supervisor
Program Manager, Module Leader

_________________________ ________________________
Prof. Khawaja Hisham Ul Hassan
Examiner Controller Examination

2
 Thesis Submitted to

Azra Naheed medical College

Superior University, Lahore, Pakistan

DECLARATION TO BE FILLED BY THE STUDENT AT THE TIME OF

SUBMISSION OF THESIS TO THE SUPERVISOR AND/OR FOR
EXTERNAL EVALUATION

Section 1: Particular of the Student

1.1 Full Name M.Tamoor Hassan
1.2 Father’s Name Maqsood Ahmad
1.3 Roll. Number 13164
1.4 Program Doctor of physical therapy

Section 2: Particular of the Thesis

2.1 Title Lateral epicondylitis in tennis players VS
badminton players
2.2 Supervisor’s Name Dr Asad
2.3 Date of Completion

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 Azra Naheed Medical College
Superior University, Lahore, Pakistan

SUPERVISOR’S CERTIFICATEON
THESIS SUBMITTED BY A STUDENT

Section 1: Particulars of the Supervisor

1.1 Full Name Dr.Asad
1.2 Address Azra Naheed Medical College, Superior University, Lahore.

Section 2: Particulars of the Student

2.1 Full Name M.Tamoor Hassan
2.2 Father’s Name Maqsood Ahmad
2.3 Registration Number DPHY 13164
2.4 Program Doctor of physical therapy

Section 3: Particulars of the Thesis

3.1 Title Lateral epicondylitis in tennis players VS badminton players
3.2 Date of Completion

I certify that:
a. The above named student has completed the cited thesis under my guidance and
supervision.
b. I am satisfied with quality of the student’s research work, and
c. I consider it worthy of submission for external evaluation.

4.1 Supervisor’s Full Signature

4.2 Date

Declaration of Originality

4
ITamoor Hassan hereby solemnly declare that this project:
a) is my original work, except where otherwise acknowledged in the text
b) has not been published earlier and
c) shall not be submitted by me in future for obtaining any degree from
this or other university or institution
d) has been incorporated HEC Plagiarism Policy
e) In case of violation of HEC Plagiarism Policy, I shall be liable to
punishable action under the plagiarism rules of HEC.

3.1 Student’s Full Signature

3.2 Date

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DEDICATION

With deepest gratitude, and affection my thesis is dedicated to my

supervisors and my teachers, who has been a constant source of inspiration

and knowledge for me.

My work is dedicated to my Father Maqsood Ahmed for earning an honest

living for us and for supporting and encouraging me to believe in myself.

ACKNOWLEDGEMENT
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First of all, I am grateful to ALLAH Almighty for enabling me to complete

this thesis.My sincere thanks to my supervisor Dr. Asad(Superior

University) who helped me a lot in doing my work.Ialso admire the help and

guidance of Dr.Umer Maqsood for imparting his knowledge and expertise

in this study.I am fortunate to have performed my graduate work at Azra

Naheed Medical College.

And special thanks to whole Department of Doctor of Physical Therapy of

Azra Naheed Medical Collegeand my friends and family, and all volunteers

sports persons.

Tamoor Hassan

ABSTRACT

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Background:

Lateral epicondylitis was common in tennis players it is usually caused by repetitive

trauma to the wrist extensors .increase pain in elbow extension causes pain. Pain is

increased by wristed radial wrist extension. Lateral epicondylitis was also caused by

repetitive injury. Recreational players were more expected to injury. Activation of flexion

muscles at the wrist can reduce the work of extensor muscles at the wrist and it may

reduce the occurrence of injury.

Objective:

1. To find association of lateral epicondylitis with type of sports in tennis and

badminton players.

2. To determine and compare pain and disability with tennis elbow in tennis and

badminton players.

Material & methods

Ananalytical assiociationstudy method was used. The inclusive criteria are fulfilled by

tennis, badminton players from different clubs of Lahore. Data will be collected after

taking informed consent.Patient- Rated Tennis Elbow Evaluation questionnaire was used

for the assessment of lateral epicondylitis in tennis and badminton players

Result:

A total p-value of pain is (0.69) which is greater than 0.05, this shows no significant

difference in the type of sports on lateral epicondylitis.

Conclusion:

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 This study conclude that there is no significant association between types of sports

played and lateral epicondylitis

Key Words:

Cozens test, lateral Epicondylitis, tennis players, badminton players

Contents
1 Introduction ...........................................................................................................11
1.1 Objective ................................................................................................................... 12
1.2 Rationale: .................................................................. Error! Bookmark not defined.
1.3 Operational definition: .............................................. Error! Bookmark not defined.

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 1.4 Hypothesis………………………………………………………………………….15
2 Literature review………………………………………………………………………..16
3 Materials and Methods…………………………..………………………………18
3.1 Study design:............................................................................................................. 18
3.2 Duration: ................................................................................................................... 18
3.3 Setting ....................................................................... Error! Bookmark not defined.
3.4 Sample size: .............................................................. Error! Bookmark not defined.
3.5 Sampling technique:.................................................. Error! Bookmark not defined.
3.6 Inclusion criteria: ...................................................................................................... 19
3.7 Exclusion criteria: ..................................................... Error! Bookmark not defined.
3.8 Tool of Data Collection: .......................................................................................... 19
3.9 Data collection procedure: ........................................................................................ 19
3.10 Ethical consideration…………………………………………………………………20
3.11 Statistical procedures…………………………………….………………………...…20
4 Results………..……………………………………………………………………..……21

5 Conclusion………………………………………………………………………………...29

6 Discussion ................................................................................................................29
7 Limitation………………………..........................................................................................30
8 References…………………………………………………………………………31
9 APENDIX; .........................................................................................................32
9.1 Consent form:............................................................................................................ 32

1. Introduction:
Lateral Epicondylitis was a painful condition which leads to decrease in function of an

elbow. Injury to the extensor carpi radialis brevis, eccentric stress to the tendons and

there is also a degenerative response. [1].

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 Lateral Epicondylitis was more common than medial Epicondylitis; lateral Epicondylitis

produces pain in the lateral aspect of elbow and forearm. Lateral Epicondylitis common

in recreational players. The most common cause of lateral Epicondylitis was the

increased wrist extension just prior to ball impact. Eccentric contractions of the extensor

carpi causes’ repetitive trauma which leads to tennis elbow injuries. By guiding the

patients with proper technique it can reduce the eccentric contractions and it reduces the

risk of injury. Tennis racquet grip plays a role in developing the disease. Proper training

and preventive exercises can decrease the load o elbow in tennis players.[2]

Patient with tennis elbow extension adduction test is performed to diagnose the tennis

elbow passive wrist flexion with and extension with a forearm in the pronated position is

performed, this test was performed for the evaluation of pain in the articular and extra-

articular tissue. When performing this test there wasan increase in tension in lateral

structures. if pain increases in wrist extension there may be neural tension.[3]

Lateral epicondylitis in badminton players is due to the repeated movements of the

racquet. The frictional force transmitted to the elbow. This causes the inflammation of the

ligaments and muscles around the joint. in some cases, complete bed rest is

recommended, and some doctors recommend to wear tight elastic band just below the

elbow to prevent reoccurrence.[4]

1.1. Objective:

1. To find association of lateral epicondylitis with type of sports in tennis and

badminton players.

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 2. To determine and compare pain and disability with tennis elbow in tennis and

badminton players.

1.2. Rationale:

The rationale was to improve the quality of life of athletes who has lateral epicondylitis.

Awareness for prevention of injury. Improvement in sports and improvements in health

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 status.

1.3. Operational Definition:

VAS (visual analog scale) was used to check the intensity of pain.

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 Cozens test, passive tennis elbow test, and Mills test, these physical tests are performed

for the confirmation of lateral epicondylitis.

Sensitivity of cozens test (84%) and specificity is (53%)

Patient-related tennis elbow questionnaire was used Reliability and internal

consistencywas excellent (PRTEE pain subscale, 0.94; PRTEE specific activities

subscale, 0.93; PRTEE usual activities, 0.85).

1.4. Hypothesis

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Null Hypothesis:

There is no significant association between lateral epicondylitis and type of sports played

in tennis and badminton players.

Alternate Hypothesis:

There is significant association between lateral epicondylitis and type of sports played in

tennis and badminton players

2. Literature Review:

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Kuo-Cheng Lo ET al.2016 did the comparison of an open stance and square stance in

ball and racket forces.The experimental study was done on male tennis players. The two-

handed backhand stroke motion was captured. As the ground reaction forces through the

trunk and upper extremity to the racket are transferred. The repetitive forces believed to

cause tennis elbow syndrome.[5]

Steve Wang et.al 2016 in their article has explained the strength difference among the

professional adults and young athlete. The cross-sectional comparative study was done on

the tennis players to check the prevalence of lateral epicondylitis and other related

injuries ranging from bruises to fractures among them. The result of the study showed

that the majority of the injuries are because of overuse and compressive forces to muscle-

tendon-bone unit in young as their bodies are not as mature as an adult professional

does.[6]

Kevin C. Chung et al. 2017 in the article upper extremity injuries in tennis players. The

epidemiologic study of tennis elbow was done followed lower extremity, trunk and upper

extremity. The study was done on both male and female athletes of National Collegiate

Athletic Association. The study concluded that tennis players are more prone to upper

extremity injuries that result from repetitive overuse motions.[7]

Eva Zeisig and martin.2015 conducted a study named lateral and medial elbow

tendinopathy. In tennis elbow, the pain felt from extensor origin. The study showed that

lateral elbow pain was the result of repetitive gripping activities in tennis players.

Overuse motions in a racket, hockey stick could involve wrist supinator along with

extensor carpi radialis muscle.[8]

Arti S Bhargava et al. 2010 in their article in which they discussed the grip strength

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 measurement in chronic lateral epicondylitis. Case-control study was done on racquet

players. The comparison was done among the athlete and non-athlete. They concluded

the study that greater grip strength is required in racket players which increase the

prevalence of lateral epicondylitis.[9]

Raham Shiri ET. Al.2006 determined the prevalence of epicondylitis. A two-stage

stratified sampling was used on the subjects included both men and women. It has found

that lateral epicondylitis prevalence was 1.3% without any difference in gender.[10]

J.Rossi et al. 2014 discussed the effect of racquet grip size forces acting on muscles of

the lateral side of the elbow. The experimental study was done to check the prevalence of

lateral epicondylitis among the racquet using players. They concluded that extensor

muscles are involved in forehand strokes. They relate the racquet grip diameter size with

overuse injury.[11]

John Jennings et al. 2009 conducted a study on recreational athletes with lateral

epicondylitis. The Interventional study was done on the players. They have discussed the

intra-articular pathology of tennis elbow which is a result of resisted wrist extension. [12]

M Azarbal ET. Al. 2004 discussed the overuse injuries of elbow among the badminton

players. Comparative study on124 badminton players were included in the study. They

took the history from players regarding the total training time. Lateral elbow pain was

noted among the players. [13]

3. Material and Methods

3.1. Study design:

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 Analytical associational study

3.2. Duration

The study was completed in 3 months after approval of synopsis.

3.3. Setting:

Tennis clubs of Lahore

Badminton clubs of Lahore

3.4. Sample Size:

The sample size was calculated using the online Rao soft.

In this formula:

x=Z(c/100)2r (100-r)

n=N x/ ((N-1) E2+x)

E=Square root [(N-n) x/ n (n-1)]

E is margin of error which is 5%

N is population size that is 20000

R is fraction of response that is 95%

Z(c/100) is the value for confidence level that is 95%

N is the sample size which was calculated to be 73

3.5. Sampling Technique:

Convenient sampling technique was used

3.6. Inclusion Criteria

Badminton players in badminton clubs of Lahore.

Tennis players in tennis clubs of Lahore.

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3.7. Exclusion Criteria:

Players who have previous history of trauma, previous history of inflammation, or may

players who have signs of radiculopathy were excluded.

3.8. Tool for Data Collection:

Patient- Rated Tennis Elbow Evaluation questionnaire was used for the assessment of

lateral epicondylitis in tennis and badminton players

3.9. Data Collection Procedure:

An analytical associational study conducted in Lahore, Pakistan in 2017, completed in a

duration of 3 months. A Sample size of 73 subjects were taken, using Rao soft online

sample size calculator. Convenient sampling technique was used.out of 73, 42 were

tennis players and 31 were badminton players .subjects were taken from different tennis

and badminton clubs of Lahore. According to defined inclusion criteria.Patient- rated

tennis elbow questionnaire was used to rating the pain, functional disabilities,and Cozens

test was also performed for diagnosis of lateral epicondylitis.the data was analyzed using

SPSS 20 version. Chi- Square test was used to find the association of type of sports.

Lateral epicondylitis Independent sample T test was used to comapre frequency of lateral

epicondylitis in tennis and bedminton players.

3.10. Ethical consideration:

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Data were taken from different sports clubs in Lahore after informed consent. It did not

affect the patient ethical values, researcher follows all ethics of medical field.

3.11. Statistical Analysis:

SPSS version 20 were used for data analysis. mean and standard deviation will be

calculated.Chi-square test and independent T- test was used.

4. Results:

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Table 1. mean standard deviation of age

Mean±SD
TennisN=42 badminton=31
Age 41.36±14.53 39.16±13.42

Mean and SD deviation of tennis players was 41.36±14.53 and bedminton

players was 39.16±13.42

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Table .2 : frequency of gender

Frequency percentage
male 71 97.3
gender
female 2 2.7

Total sample size of 73 has been taken 97.3% male and 2.7% were

females .

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 Table -3: frequency of tennis and badminton players.

Frequency percentage
Tennis 42 57.5
Games
Badminton 31 42.5

Total sample of 73 has been taken 57.5 % tennis players and 42.5 %

badminton players.

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Table -4cozens test interpretation

Games p- value
Total
Tennis Badminton
Cozens test
positive 29 7 36 0.00
negative 13 24 37

Sample size of 73 individuals is taken 29 tennis players have positive cozen

test 13 tennis players show negative cozen test.7 badminton players show

positive cozen tests and 24 badminton players show negative cozen test .

Table -5: showing pain rate in different in different activities in tennis and
badminton players.
PR1
total P value
When you are at rest

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 0 1 2 3 4 5
tennis 21 9 3 4 2 3 42 0.72
badminton 26 0 2 2 2 31
When doing a task with repeated arm movement
0 1 2 3 4 5 42
Tennis 17 8 8 7 1 1 31 0.00
Badminton 19 2 0 3 1 6 73
Carrying a grocery bag or briefcase by the handle
0 1 2 5 8
Tennis 22 16 2 1 1 42 0.01
Games
badminton 28 3 0 0 0 31
When your pain was at its least
0 1 2 4
Tennis 33 7 1 1 42 0.10
badminton 26 1 2 2 31
When your pain was at its worst
0 1 2 3 4 5
Tennis 27 11 1 1 1 1 42 0.10
badminton 27 1 2 0 1 0 31

Pain in different activities in question 1: P- value (0.72) showing no

significant difference, in question 2: P- value (0.00) showing significant

difference, in question 3: p-value (0.01) showing significant difference, in

question 4: p- value (0.10) showing no significant difference, in question 5:

p- value (0.10) showing no significant difference.

Table 6 showing functional disabilities in tennis and badminton players

Functional disability P
total
Turn a doorknob or key value
0 1 2 3 5
tennis 30 7 3 2 0 42 0.11
Games badminton 28 2 0 0 1 31
Carry a grocery bag or briefcase by the handle

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 0 1 2 5 8
Tennis 22 16 2 1 1 42 0.01
Badminton 28 3 0 0 0 310
Lift a full coffee cup or glass of milk to your
mouth
0 1 2 3 4 5 7
Tennis 31 5 0 2 1 0 1 42 0.10
badminton 27 1 0 0 0 3 0 31
Open a jar
0 1 3 4 5
Tennis 31 0 1 0 1 42 0.03
badminton 26 0 2 2 1 31
Pull up pants
0 1 2 3 4 5
Tennis 34 4 2 1 0 1 42 0.29
badminton 27 1 0 0 2 1
Wring out a washcloth or wet towel
0 1 3 4 5
3
Tennis 31 8 0 0 42 0.07
Badminton 26 2 0 2 1 31

Functional disability in question 1: p - value (0.11) show no significant

difference, in question 2: p-value (0.01) showing significant difference, in

question 3: p value (0.10) showing no significant difference, in question 4:

p-value (0.03) showing significant difference, in question 5: p-value (0.29)

shows no significant difference, in question 6: p-value (0.07) showing no

significant difference.

Table -7 showing problem in usual activities in tennis and badminton

players.
Usual activities
total P value
Personal Activities ( dressing, Washing)
0 1 2 3 4 5
tennis 20 14 6 2 0 0 42 0.01
badminton 22 4 1 0 2 2 31
Games
Household work (cleaning, Maintenance)
0 1 2 3 4 5 0.16

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 Tennis 31 6 3 1 1 0 42
Badminton 25 1 2 0 0 3 31
Work (your job or everyday work)
0 1 2 4 5
Tennis 22 11 9 0 0 42 0.00
badminton 24 11 12 2 2 31
Recreational or sporting activities
0 1 2 3 5
Tennis 22 14 2 2 2 42 0.08
badminton 24 3 3 1 0 31

Usual activities in question1 shows p-value (0.01) show a significant

difference, in question 2: p-value (0.16) showing no difference, in question
3: p-value (0.00) showing a significant difference, in quest 4: p-value (0.08)
showing no significant difference

Table 8- mean and standard deviation of pain score in tennis and

badminton players.
P
Mean±SD
value
TennisN=42 badminton=31
Total score 7.02±6.56 6.38±7.19 0.69

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Mean and standard of pain rate p-value (0.69) showing no significant

difference in the ratio of pain in all activities i.e. pain rate, functional

disabilities, usual activities.

5. Conclusion:

This study concludes that there is no significant association between type of

sportsplayed and lateral epicondylitis.

6. Discussion:

According to study when cozen test applied to both game players i.e. tennis and

28
badminton it shows a significant difference in pain score. But when we asked different

questions related to pain,functionaldisabilities, and usual activities some shows the minor

difference and some shows no difference in p values.

Lateral epicondylitis is a common problem in tennis players; it is caused by repetitive

trauma to the extensor muscles of the wrist. Players who play games off and on and

without an instructor they are more prone to develop this condition, different tests are

performed to evaluate this condition conservative management is used to treat this

disorder ( Thomas De Smedt et. Al)

According to a study racquet sports have a large prevalence to cause injury in sports, in

badminton lateral epicondylitis is also occur but its prevalence is low, it depends on the

mechanism of injury to a way that a player grasps a racquet during a game. (M.D Chard

Et Al).

According to study a survey of elbow injuries in badminton players shows 9.8% of

badminton players had history of lateral epicondylitis, pain usually occur during training

session, and it may show degenerative changes, or it may be a radial tunnel syndrome,

they also explain elbow injuries have more prevalence of injury and medial epicondylitis

is more common as compared to lateral epicondylitis in badminton players.(M. Azarbal

Et.al).

7. Limitations:

Number of female players was much as compared to number of male players.

Results could be more reliable if randomized sampling was used instead of

convenient sampling.

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 All badminton and tennis clubs of Lahore were not catered.

8. References:

1. Faro, F. and J.M. Wolf, Lateral epicondylitis: review and current concepts. The
Journal of hand surgery, 2007. 32(8): p. 1271-1279.
2. Eygendaal, D., F.T.G. Rahussen, and R. Diercks, Biomechanics of the elbow joint
in tennis players and relation to pathology. British journal of sports medicine, 2007.
41(11): p. 820-823.

30
 3. Hyland, S., J. Nitschke, and T.A. Matyas, The extension-adduction test in chronic
tennis elbow: soft tissue components and joint biomechanics. Australian journal of
Physiotherapy, 1990. 36(3): p. 147-153.
4. Arthur, H., Aid for relieving or preventing tennis elbow injury. 1975, Google
Patents.
5. Ashima, N., Sports Injury and Its Medication. BioTechnology: An Indian Journal,
2016. 12(12).
6. Wang, S. and M. Hausman, Elbow, Wrist, and Hand Injuries in the Young Tennis
Athlete, in The Young Tennis Player. 2016, Springer. p. 167-182.
7. Chung, K.C. and M.E. Lark, Upper Extremity Injuries in Tennis Players:
Diagnosis, Treatment, and Management. Hand Clinics, 2017. 33(1): p. 175-186.
8. Zeisig, E. and M. Fahlström, Lateral and Medial Elbow Tendinopathies. Sports
Injuries: Prevention, Diagnosis, Treatment and Rehabilitation, 2015: p. 587-592.
9. Bhargava, A.S., C. Eapen, and S.P. Kumar, Grip strength measurements at two
different wrist extension positions in chronic lateral epicondylitis-comparison of
involved vs. uninvolved side in athletes and non athletes: a case-control study. BMC
Sports Science, Medicine and Rehabilitation, 2010. 2(1): p. 22.
10. Shiri, R., et al., Prevalence and determinants of lateral and medial epicondylitis:
a population study. American journal of epidemiology, 2006. 164(11): p. 1065-1074.
11. Rossi, J., et al., Potential effects of racket grip size on lateral epicondilalgy risks.
Scandinavian journal of medicine & science in sports, 2014. 24(6): p. e462-470.
12. Merrell, G. and M.F. DaSilva, Arthroscopic treatment of lateral epicondylitis. The
Journal of hand surgery, 2009. 34(6): p. 1130-1134.
13. Azarbal, M., et al., A survey of elbow injuries in badminton players. The Internet
Journal of Orthopedic Surgery, 2004. 2(1).

9. APPENDIX:

Consent form:

The study you are about to participate is to determine theLateral epicondylitis in tennis

31
 players VS badminton players.The study has no potential harm to participants. All data

collected from you will be coded in order to protect your identity, and should not be

disclosed to anyone. Following the study, there will be no way to connect your name with

your data.

You are free to withdraw from the study at any time. You agree to participate, indicating

that you have read and understood the nature of the study, and that all your inquiries

concerning the activities have been answered to your satisfaction.

1) Name: ____________________

2) Age: ____________________

3) Select one: 1) tennis 2) bad Minton

Date: __________________ Signature: _______________

PATIENT-RATEDTENNISELBOWEVALUATION

The questions below will help us understand the amount of difficulty you have had with your arm

in the past week. You will be describing your average arm symptoms over the past week on a

scale 0-10. Please provide an answer for all questions. If you did not perform an activity

32
Because of pain or because you were unable, then you should circle a “10”. If you are unsure

please estimate to the best of your ability. Only leave items blank if you never perform that

activity. Please indicate this by drawing a line completely through the question.

1. PAIN in your affected arm

Rate the average amount of pain in your armover the past week by circling the number that
best describes your pain on a scale from 0-10. Azero (0)means that you did not have any pain
and a ten (10)means that you had the worst pain imaginable.

RATE YOUR PAIN: Worst

No Pain Imaginable

When you are at rest 0 1 2 3 4 5 6 7 8 9 10

When doing a task with repeated arm 0 1 2 3 4 5 6 7 8 9 10

movement
When carrying a plastic bag of groceries 0 1 2 3 4 5 6 7 8 9 10
When your pain was at its least 0 1 2 3 4 5 6 7 8 9 10
When your pain was at its worst 0 1 2 3 4 5 6 7 8 9 10

33
2. FUNCTIONAL DISABILITY
A. SPECIFIC ACTIVITIES
Rate theamount of difficulty you experienced performing each of the tasks listed
below, over the past week, by circling the number that best describes your difficulty on a
scale of 0-10. A zero (0)means you did not experience any difficulty and a ten (10)means it
was so difficult you were unable to do it at all.
No
Unable
Difficulty To
Do
Turn a doorknob or key 0 1 2 3 4 5 6 7 8 9 10

Carry a grocery bag or briefcase by the 0 1 2 3 4 5 6 7 8 9 10

handle
Lift a full coffee cup or glass of milk to 0 1 2 3 4 5 6 7 8 9 10
your mouth
Open a jar 0 1 2 3 4 5 6 7 8 9 10
Pull up pants 0 1 2 3 4 5 6 7 8 9 10
Wring out a washcloth or wet towel 0 1 2 3 4 5 6 7 8 9 10
B. USUAL ACTIVITIES
Rate theamount of difficulty you experienced performing your usualactivities in each
of the areas listed below, over the past week, by circling the number that best describes
your difficulty on a scale of 0-10. By “usual activities”, we mean the activities that you
performed before you started having a problem with your arm. A zero (0)means you did
not experience any difficulty and a ten (10)means it was so difficulty you were unable to do
any of your usual activities.

1. Personal activities (dressing, washing) 0 1 2 3 4 5 6 7 8 9 10

2. Household work (cleaning, maintenance) 0 1 2 3 4 5 6 7 8 9 10

3. Work (your job or everyday work) 0 1 2 3 4 5 6 7 8 9 10
4. Recreational or sporting activities 0 1 2 3 4 5 6 7 8 9 10

34