Arch Phys Med Rehabil. 1999 Apr;80(4):453-7.

Shoulder pain in wheelchair users with tetraplegia and paraplegia.

Curtis KA, Drysdale GA, Lanza RD, Kolber M, Vitolo RS, West R.

Source
Department of Orthopaedics and Rehabilitation, University of Miami School of Medicine, FL, USA.

Abstract
OBJECTIVE: To compare the prevalence and intensity of shoulder pain experienced during daily functional activities in individuals with tetraplegia and individuals with paraplegia who use manual wheelchairs. DESIGN: Self-report survey. SETTING: General community. PARTICIPANTS: Fifty-five women and 140 men, 92 subjects with tetraplegia and 103 subjects with paraplegia who met inclusion criteria of 3 hours per week of manual wheelchair use and at least 1 year since onset of spinal cord injury. MAIN OUTCOME MEASURES: Respondents completed a demographic and medical history questionnaire and the Wheelchair User's Shoulder Pain Index (WUSPI), a measure of pain during typical daily activities. RESULTS: More than two thirds of the sample reported shoulder pain since beginning wheelchair use, with 59% of the subjects with tetraplegia and 42% of the subjects with paraplegia reporting current pain. Performance-corrected WUSPI scores were significantly higher in subjects with tetraplegia than in subjects with paraplegia. CONCLUSIONS: Both the prevalence and intensity of shoulder pain was significantly higher in subjects with tetraplegia than in subjects with paraplegia. Efforts to monitor and prevent shoulder pain should continue after rehabilitation. PMID: 10206610 [PubMed - indexed for MEDLINE] Arch Phys Med Rehabil. 2008 Nov;89(11):2086-93. doi: 10.1016/j.apmr.2008.05.015.

Shoulder ultrasound abnormalities, physical examination findings, and pain in manual wheelchair users with spinal cord injury.
Brose SW, Boninger ML, Fullerton B, McCann T, Collinger JL, Impink BG, Dyson-Hudson TA.

Source
Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA. [email protected]

Abstract
OBJECTIVES: To investigate the presence of ultrasound (US) abnormalities in manual wheelchair users with spinal cord injury (SCI) using a quantitative Ultrasound Shoulder Pathology Rating Scale (USPRS). To investigate physical examination (PE) findings using a quantitative Physical Examination of the Shoulder Scale (PESS), and to obtain data about pain and other subject characteristics such as age, years with SCI, and weight. DESIGN: Case series. SETTING: National Veterans' Wheelchair Games 2005 and 2006. PARTICIPANTS: Volunteer sample of manual wheelchair users with SCI participating in the National Veterans' Wheelchair Games. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Presence of relationships between US findings, PE findings, pain, and subject characteristics. RESULTS: The USPRS correlated with age, duration of SCI, and weight (all P<.01), and showed a positive trend with the total Wheelchair User's Shoulder Pain Index (WUSPI) score (r=.258, P=.073). Several US findings related to presence of PE findings for specific structures. The PESS score correlated with the WUSPI (r=.679, P<.001) and duration of SCI (P<.05). The presence of untreated shoulder pain that curtailed activity was noted in 24.5% of subjects, and this was related to increased WUSPI scores (P=.002). CONCLUSIONS:

PE and US abnormalities are common in manual wheelchair users with SCI. The USPRS and PESS demonstrated evidence for external validity and hold promise as research tools. Untreated shoulder pain is common in manual wheelchair users with SCI, and further investigation of this pain is indicated. PMID: 18996236 [PubMed - indexed for MEDLINE]

J Rehabil Med. 2008 Apr;40(4):277-83. doi: 10.2340/16501977-0173.

Shoulder pain in persons with thoracic spinal cord injury: prevalence and characteristics.
Alm M, Saraste H, Norrbrink C.

Source
Spinalis SCI Unit, Karolinska University Hospital, Stockholm, Sweden. [email protected]

Abstract
OBJECTIVE: To document the prevalence of shoulder pain, associated patient characteristics, and intensity and interference with shoulder function in activities in wheelchair users. DESIGN: A cross-sectional survey. PATIENTS: Individuals with a thoracic spinal cord injury. METHODS: A 3-part questionnaire on patient characteristics, medical history, supplemental questions, and the Wheelchair Users Shoulder Pain Index was administered to 101 patients. RESULTS: Of the 88 subjects (87%) who completed the questionnaire, 40% reported experiencing current shoulder pain, often chronic in nature. The highest median intensity of shoulder pain was reported for pushing the wheelchair up ramps or inclines outdoors. Reports of limitations regarding the ability to use the shoulder in activities were common. Most subjects used no upper extremity assistive devices during transfer or wheelchair propulsion. Of those with current shoulder pain, 37% had not sought medical attention. Age was associated with ongoing shoulder pain. CONCLUSION: Shoulder pain is a common problem in wheelchair users with a thoracic spinal cord injury, it seems more likely to occur with increased age, and is a potential cause of activity limitations. The findings indicate a need to develop programmes of prevention, patient education, diagnosis and treatment, possibly including more frequent use of upper extremity assistive devices. PMID: 18382823 [PubMed - indexed for MEDLINE] Free full text

J Clin Rheumatol. 2006 Aug;12(4):179-86.

Shoulder pain in the traumatically injured spinal cord patient: evaluation of risk factors and function.
McCasland LD, Budiman-Mak E, Weaver FM, Adams E, Miskevics S.

Source
Department of Rheumatology, Loyola University Medical Center, Maywood, and Department of Veterans Affairs, Hines VA Hospital, Hines, Illinois 60141-9910, USA.

Abstract
BACKGROUND: Shoulder pain in individuals with traumatic spinal cord injury (TSCI) is common and frequently results in chronic debilitating pain recalcitrant to treatment. OBJECTIVE: Our objectives were to identify the risk factors associated with shoulder pain in the TSCI population. METHODS: A telephone survey and medical record review were conducted on a convenience sample of patients with TSCI. Data variables included: Shoulder Pain and Disability Index (SPADI), demographics, injury type, treatment histories for shoulder pain/dysfunction, assistive device use, and radiographic imaging. RESULTS: Respondents (n=63) were male (96%) and tetraplegia (51%) with a mean age of 58.1 years. The majority of patients (70%) currently had shoulder pain, one third had previous injury to the shoulder, and 52% reported bilateral pain. Tetraplegics had higher prevalence (80%) of shoulder pain and higher total SPADI scores than paraplegics (P=0.001). Previous shoulder trauma increased the likelihood of shoulder pain. Self-care posed their most difficult task. Use of a manual wheelchair (71%) and/or trapeze bar (51%) was common. However, no differences were found in wheelchair or trapeze bar use or average body mass index between groups with and without pain. Respondents with pain tended to use trapeze bars less. Of the respondents reporting shoulder pain, an estimated 57% received physical therapy and massage with most reporting some benefit; 53% had pharmaceutical treatment with variable effect. CONCLUSION: Shoulder pain is common in patients with TSCI. Tetraplegics fared worse than paraplegics. Pain may limit transfer because respondents with pain used trapeze bars less. Understanding and addressing the factors contributing to shoulder pain in this vulnerable population is sorely needed. PMID: 16891921 [PubMed - indexed for MEDLINE]

J Spinal Cord Med. 2004;27(1):4-17.

Shoulder pain in chronic spinal cord injury, Part I: Epidemiology, etiology, and pathomechanics.
Dyson-Hudson TA, Kirshblum SC.

Source
Kessler Medical Rehabilitation Research and Education Corporation, Spinal Cord Injury Rehabilitation Research, West Orange, New Jersey 07052, USA. [email protected]

Abstract
STUDY DESIGN: Review of the literature. BACKGROUND/OBJECTIVE: Shoulder pain is extremely common in individuals with chronic spinal cord injury (SCI) and is a source of morbidity and functional loss. The purpose of this review is to outline the present knowledge of the epidemiology, etiology, and pathomechanics of musculoskeletal shoulder pain in individuals with chronic SCI. METHODS: Review of the literature using PubMed/MEDLINE, EMBASE, and bibliographies of selected articles. RESULTS: Shoulder pain is more common in individuals with tetraplegia and complete injuries and may occur more frequently in women. Musculoskeletal conditions, primarily injuries to the rotator cuff, are most common. Risk factors include the duration of injury, older age, higher body mass index, the use of a manual wheelchair, poor seated posture, decreased flexibility, and muscle imbalances in the rotator cuff and scapular stabilizing muscles. CONCLUSION: With a better understanding of the epidemiology, etiology, and basic pathomechanics of shoulder pain in SCI, physicians are in a better position to evaluate, treat, and prevent these disorders. PMID: 15156931 [PubMed - indexed for MEDLINE]

J Rehabil Res Dev. 2005 May-Jun;42(3 Suppl 1):9-19.

Pushrim biomechanics and injury prevention in spinal cord injury: recommendations based on CULP-SCI investigations.
Boninger ML, Koontz AM, Sisto SA, Dyson-Hudson TA, Chang M, Price R, Cooper RA.

Source
Department of Physical Medicine and Rehabilitation, University of Pittsburgh, PA 15213, USA. [email protected]

Abstract
Over 50 percent of manual wheelchair users with spinal cord injury (SCI) are likely to develop upperlimb pain and injury. The majority of studies related to pain have implicated wheelchair propulsion as a cause. This paper draws from a large multisite trial and a long-standing research program to make specific recommendations related to wheelchair propulsion that may decrease the risk of upper-limb injury. The studies include over 60 subjects over 1 yr after a traumatic SCI below the second thoracic level. Specific aspects of the propulsive stroke that may relate to injury include cadence, magnitude of force, and the pattern of the hand during the nonpropulsive part of the stroke. Lower peak forces, slower cadence, and a circular propulsive stroke in which the hand falls below the pushrim during recovery may help prevent injury. In addition, wheelchair users should use the lightest weight adjustable wheelchair possible. Future work should include interventional trials and larger studies that allow for more complex statistical models that can further detail the relationship between wheelchair propulsion, user characteristics, and upper-limb injuries. PMID: 16195959 [PubMed - indexed for MEDLINE]

Disabil Rehabil Assist Technol. 2011;6(5):365-77. doi: 10.3109/17483107.2010.525290. Epub 2010 Oct 11.

Wheelchair propulsion biomechanics and wheelers' quality of life: an exploratory review.

Chow JW, Levy CE.

Source
Methodist Rehabilitation Center, Jackson, MS 39110, USA. [email protected]

Abstract
PURPOSE. To provide an overview of associations between wheelchair propulsion biomechanics for both everyday and racing wheelchairs, wheeling-related upper limb injuries, and quality of life of manual wheelchair users through a synthesis of the available information. METHODS. A search of publications was carried out in PubMed and SportsDiscus databases. Studies on wheelchair propulsion biomechanics, upper limb injuries associated with wheelchair propulsion and quality of life of wheelchair users were identified. Relevant articles cited in identified articles but not cited in PubMed or SportsDiscus were also included. RESULTS. Wheelchair sports participation has positive impact on quality of life and research in racing wheelchair biomechanics can indirectly promote the visibility of wheelchair sports. The impact of pushrim-activated power-assisted wheelchairs (a hybrid between manual and battery-powered wheelchairs) and geared manual wheels on wheelers' everyday life were discussed. CONCLUSIONS. The study of wheelchair propulsion biomechanics focuses on how a wheelchair user imparts power to the wheels to achieve mobility and the accumulated knowledge can help to improve wheelchair users' mobility, reduce physical stress associated with wheelchair propulsion, and as a result, enhance quality of life. PMID: 20932232 [PubMed - indexed for MEDLINE]

Sports Med. 2001;31(5):339-67.

Wheelchair propulsion biomechanics: implications for wheelchair sports.

Vanlandewijck Y, Theisen D, Daly D.

Source
Department of Rehabilitation Sciences, Faculty of Physical Education and Physiotherapy, Katholieke Universiteit Leuven, Belgium. [email protected]

Abstract
The aim of this article is to provide the reader with a state-of-the-art review on biomechanics in hand rim wheelchair propulsion, with special attention to sport-specific implications. Biomechanical studies in wheelchair sports mainly aim at optimising sport performance or preventing sport injuries. The sports performance optimisation question has been approached from an ergonomic, as well as a skill proficiency perspective. Sports medical issues have been addressed in wheelchair sports mainly because of the extremely high prevalence of repetitive strain injuries such as shoulder impingement and carpal tunnel syndrome. Sports performance as well as sports medical reflections are made throughout the review. Insight in the underlying musculoskeletal mechanisms of hand rim wheelchair propulsion has been achieved through a combination of experimental data collection under realistic conditions, with a more fundamental mathematical modelling approach. Through a synchronised analysis of the movement pattern, force generation pattern and muscular activity pattern, insight has been gained in the hand rim wheelchair propulsion dynamics of people with a disability, varying in level of physical activity and functional potential. The limiting environment of a laboratory, however, has hampered the drawing of sound conclusions. Through mathematical modelling, simulation and optimisation (minimising injury and maximising performance), insight in the underlying musculoskeletal mechanisms during wheelchair propulsion is sought. The surplus value of inverse and forward dynamic simulation of hand rim stroke dynamics is addressed. Implications for hand rim wheelchair sports are discussed. Wheelchair racing, basketball and rugby were chosen because of the significance and differences in sport-specific movement dynamics. Conclusions can easily be transferred to other wheelchair sports where movement dynamics are fundamental. PMID: 11347685 [PubMed - indexed for MEDLINE]

2001 Dec;23(10):713-33.

Biomechanics and physiology in active manual wheelchair propulsion.

van der Woude LH, Veeger HE, Dallmeijer AJ, Janssen TW, Rozendaal LA.

Source
Institute for Fundamental and Clinical Human Movement Science, Faculty of Human Movement Sciences, Vrije Universiteit, Van der Boechorststraat 9, 1081 BT Amsterdam, The Netherlands. [email protected]

Abstract
Manual wheelchair propulsion in daily life and sports is increasingly being studied. Initially, an engineering and physiological perspective was taken. More recently a concomitant biomechanics interest is seen. Themes of biomechanical and physiological studies today are performance enhancing aspects of wheelchair use and the ergonomics of wheelchair design. Apart from the propulsion technique the focus of biomechanics research of manual wheelchair propulsion is mainly towards injury mechanisms, especially phenomena of overuse to the upper extremity. Obviously, the vehicle mechanics of wheelchairs must be included within this biological framework. Scientific research is progressing, but is still hampered by methodological limitations, such as the heterogeneity and small numbers of the population at study as well as the inconsistency of employed technologies and methodologies. There is a need for consensus regarding methodology and research strategy, and a strong need for collaboration to improve the homogeneity and size of subject groups and thus the power of the experimental results. Thus a sufficiently strong knowledge database will emerge, leading to an evidence-base of performance enhancing factors and the understanding of the risks of wheelchair sports and long-term wheelchair use. In the light of the current biomechanical and physiological knowledge of manual wheelchair propulsion there seems to be a need for the stimulation of other than hand rim propelled manual wheelchairs. PMID: 11801413 [PubMed - indexed for MEDLINE]

Am J Phys Med Rehabil. 2008 Dec;87(12):984-91. doi: 10.1097/PHM.0b013e31818a52cc.

Influence of varying level terrain on wheelchair propulsion biomechanics.

Hurd WJ, Morrow MM, Kaufman KR, An KN.

Source
Department of Orthopaedic Research, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota 55095, USA.

Abstract
OBJECTIVE: To evaluate manual wheelchair propulsion across level ground conditions that are encountered during everyday life. DESIGN: Subjects included 14 individuals (13 with spinal cord injury [SCI], 1 with spina bifida) who were experienced manual wheelchair users and had no current upper extremity injury or pain complaints. Subjects propelled their wheelchairs at a self-selected speed across four different level ground conditions, including smooth and aggregate concrete and tile and carpet flooring. Temporal and kinetic measurements were obtained bilaterally from instrumented wheelchair rims during the steadystate phase of propulsion. RESULTS: There were no side-to-side differences for any of the temporal or kinetic variables. Propulsion velocity and pushrim contact time were consistent across ground conditions. Propulsion frequency was significantly greater during both concrete conditions than either tile or carpet ground conditions. Forces and moments were greatest during the aggregate concrete ground condition and lowest during propulsion across tile flooring. CONCLUSIONS: The rolling resistance of level surface terrain significantly impacts wheelchair propulsion biomechanics. Identification of environmental conditions that may contribute to upper extremity pathology is a step toward injury prevention and maintenance of functional abilities for the manual wheelchair user. These results may be used to assist with home and community terrain design to minimize the demands associated with wheelchair propulsion. PMID: 18824889 [PubMed - indexed for MEDLINE]

Int J Rehabil Res. 2011 Dec;34(4):282-9. doi: 10.1097/MRR.0b013e32834a8fd9.

Shoulder pain in cases of spinal injury: influence of the position of the wheelchair seat.
Giner-Pascual M, Alcanyis-Alberola M, Millan Gonzlez L, Aguilar-Rodrguez M, Querol F.

Source
Unidad de Lesionados Medulares, Servicio de Rehabilitacin, Hospital Universitario La Fe de Valencia, Spain. [email protected]

Abstract
The objective of this study was to determine the relationship between shoulder pain and the position of the seat of a wheelchair relative to the ground and to determine the relationship between shoulder pain and structural damage. A transversal study of a patient cohort of 140 patients with grade A and B spinal cord injuries below the T1 vertebra, who were full-time users of self-propelled wheelchairs, was made. The main variables are angle of the seat of the wheelchair, nuclear magnetic resonance measurements, shoulder joint range, Spinal Cord Index Measurement scale value, Wheelchair User Shoulder Pain Index and visual analogue scale value. Of the 140 patients, 99 were males (70.7%), and 41 were females (29.3%). Of these patients, 78 (55.7%) used a wheelchair seat at a straight angle, whereas 62 (44.3%) maintained an acute angle. A total of 57 (40.7%) patients presented shoulder pain within the last 6 months, and 83 (59.3%) did not. Sixty-nine (49.3%) did not present any type of shoulder injury as determined by nuclear magnetic resonance, whereas 71 (50.7%) had pathological signs. Patients with the seat at a straight angle developed 1.86 times (P<0.01) more shoulder pain and 1.73 times (P<0.001) more structural injuries than those with seats at an acute angle. Patients with structural abnormalities suffered 6.3-fold greater shoulder pain (P<0.001) than those without abnormalities. Wheelchair seats positioned parallel to the ground may be a risk factor for pain and shoulder injury. Patients with structural injuries in their shoulders have a greater risk of shoulder pain. PMID: 21971486 [PubMed - indexed for MEDLINE]

Sports Med. 2002;32(1):23-51.

Physiology of wheelchair racing in athletes with spinal cord injury.

Bhambhani Y.

Source
Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada. [email protected]

Abstract
Wheelchair racing is one of the most popular sporting activities of individuals with spinal cord injury. Athletes with this impairment have unique changes in metabolic, cardiorespiratory, neuromuscular and thermoregulatory systems, which reduce their overall physiological capacity compared with ablebodied individuals or individuals with other types of impairments. This review on spinal cord injury: presents the International Stoke Mandeville Games Federation classification of wheelchair athletes; describes methods commonly used to characterise anaerobic and aerobic fitness; presents the findings of physiological studies that have evaluated wheelchair racing performance; identifies the risks associated with temperature regulation when competing in wheelchair races; and discusses special conditions that can influence wheelchair racing performance. Currently there is limited research that has examined the relationship between sprint or distance wheelchair racing performance and the anaerobic and aerobic components of physical fitness. Although the descriptive evidence indicates that the profiles of these athletes reflect their training and participation in these specific events, the association between their physiological profiles and real or simulated racing performance is unclear. The generally accepted concept that high values of aerobic and anaerobic power are strongly correlated with endurance and sprint racing performance, respectively, are not necessarily true in this population. Athletes with spinal cord injury have an impaired thermoregulatory capacity, because the compromised autonomic and somatic nervous system functions disrupt control of skin blood flow and sweating below the level of the lesion. As a result, they may be more susceptible to hyperthermia during distance wheelchair racing performance. Wheelchair athletes should follow recommendations advocated for able-bodied individuals to minimise their risks of heat stress during competition. Many athletes with quadriplegia voluntarily induce autonomic dysreflexia (commonly known as boosting) during distance racing events to improve performance. Experimental evidence indicates that boosting can improve performance time by 10% in elite wheelchair marathon racers during simulated racing, as a result of increased oxygen utilisation in the boosted state. However, since boosting can be dangerous to health, the International Paralympic Committee has banned athletes from voluntarily inducing it during competition. The use of anti-gravity suits to increase lower-body positive pressure can increase the peak oxygen uptake, cardiac output and stroke volume. However, the use of abdominal binders does not influence these physiological responses. An effect of either of these techniques on wheelchair racing performance has not been demonstrated. PMID: 11772160 [PubMed - indexed for MEDLINE]

Arch Phys Med Rehabil. 2008 Oct;89(10):1996-2002. doi: 10.1016/j.apmr.2008.03.020.

Biomechanic evaluation of upper-extremity symmetry during manual wheelchair propulsion over varied terrain.
Hurd WJ, Morrow MM, Kaufman KR, An KN.

SourceCollege of Medicine, Department of Orthopedic Research, Mayo Clinic, Rochester, MN, USA. Abstract
OBJECTIVE: To evaluate upper-extremity symmetry during wheelchair propulsion across multiple terrain surfaces. DESIGN: Case series. SETTING: A biomechanics laboratory and the general community. PARTICIPANTS: Manual wheelchair users (N=12). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Symmetry indexes for the propulsion moment, total force, tangential force, fractional effective force, time-to-peak propulsion moment, work, length of push cycle, and power during wheelchair propulsion over outdoor and indoor community conditions, and in laboratory conditions. RESULTS: Upper-extremity asymmetry was present within each condition. There were no differences in the magnitude of asymmetry when comparing laboratory with indoor community conditions. Outdoor community wheelchair propulsion asymmetry was significantly greater than asymmetry measured during laboratory conditions. CONCLUSIONS: Investigators should be aware that manual wheelchair propulsion is an asymmetrical act, which may influence interpretation when data is collected from a single limb or averaged for both limbs. The greater asymmetry identified during outdoor versus laboratory conditions emphasizes the need to evaluate wheelchair biomechanics in the user's natural environment. PMID: 18929029 [PubMed - indexed for MEDLINE]

Disabil Rehabil Assist Technol. 2011;6(5):365-77. doi: 10.3109/17483107.2010.525290. Epub 2010 Oct 11.

Wheelchair propulsion biomechanics and wheelers' quality of life: an exploratory review.

Chow JW, Levy CE.

Source
Methodist Rehabilitation Center, Jackson, MS 39110, USA. [email protected]

Abstract
PURPOSE. To provide an overview of associations between wheelchair propulsion biomechanics for both everyday and racing wheelchairs, wheeling-related upper limb injuries, and quality of life of manual wheelchair users through a synthesis of the available information. METHODS. A search of publications was carried out in PubMed and SportsDiscus databases. Studies on wheelchair propulsion biomechanics, upper limb injuries associated with wheelchair propulsion and quality of life of wheelchair users were identified. Relevant articles cited in identified articles but not cited in PubMed or SportsDiscus were also included. RESULTS. Wheelchair sports participation has positive impact on quality of life and research in racing wheelchair biomechanics can indirectly promote the visibility of wheelchair sports. The impact of pushrim-activated power-assisted wheelchairs (a hybrid between manual and battery-powered wheelchairs) and geared manual wheels on wheelers' everyday life were discussed. CONCLUSIONS. The study of wheelchair propulsion biomechanics focuses on how a wheelchair user imparts power to the wheels to achieve mobility and the accumulated knowledge can help to improve wheelchair users' mobility, reduce physical stress associated with wheelchair propulsion, and as a result, enhance quality of life.

J Rehabil Res Dev. 2005 May-Jun;42(3 Suppl 1):9-19.

Pushrim biomechanics and injury prevention in spinal cord injury: recommendations based on CULP-SCI investigations.
Boninger ML, Koontz AM, Sisto SA, Dyson-Hudson TA, Chang M, Price R, Cooper RA.

Source
Department of Physical Medicine and Rehabilitation, University of Pittsburgh, PA 15213, USA. [email protected]

Abstract
Over 50 percent of manual wheelchair users with spinal cord injury (SCI) are likely to develop upperlimb pain and injury. The majority of studies related to pain have implicated wheelchair propulsion as a cause. This paper draws from a large multisite trial and a long-standing research program to make specific recommendations related to wheelchair propulsion that may decrease the risk of upper-limb injury. The studies include over 60 subjects over 1 yr after a traumatic SCI below the second thoracic level. Specific aspects of the propulsive stroke that may relate to injury include cadence, magnitude of force, and the pattern of the hand during the nonpropulsive part of the stroke. Lower peak forces, slower cadence, and a circular propulsive stroke in which the hand falls below the pushrim during recovery may help prevent injury. In addition, wheelchair users should use the lightest weight adjustable wheelchair possible. Future work should include interventional trials and larger studies that allow for more complex statistical models that can further detail the relationship between wheelchair propulsion, user characteristics, and upper-limb injuries. PMID: 16195959 [PubMed - indexed for MEDLINE]

Arch Phys Med Rehabil. 2007 Jan;88(1):81-7. Stroke pattern and handrim biomechanics for level and uphill wheelchair propulsion at self-selected speeds. Richter WM, Rodriguez R, Woods KR, Axelson PW. Source MAX Mobility LLC, Nashville, TN; Beneficial Designs Inc, Nashville, TN, USA. [email protected] Abstract OBJECTIVES: To investigate the natural stroke patterns of wheelchair users pushing on a level surface, to determine if users adapt their stroke patterns for pushing uphill, and to assess whether there are biomechanic advantages to one or more of the stroke patterns. DESIGN: Case series. SETTING: Biomechanics laboratory. PARTICIPANTS: Twenty-six manual wheelchair users with a spinal cord injury. INTERVENTION: Subjects pushed their own wheelchairs at self-selected speeds on a research treadmill set to level, 3 degrees , and 6 degrees grades. Stroke patterns were measured using a motion capture system. Handrim biomechanics were measured using an instrumented wheel. MAIN OUTCOME MEASURES: Stroke patterns were classified for both level and uphill propulsion according to 1 of 4 common classifications: arcing, semi-circular, single-looping (SLOP), and double-looping (DLOP). Biomechanic outcomes of speed, peak handrim force, cadence, and push angle were all compared across stroke classifications using an analysis of variance. RESULTS: Only 3 of the 4 stroke patterns were observed. None of the subjects used the semi-circular pattern. For level propulsion, the stroke patterns were fairly balanced between arcing (42%), SLOP (31%), and DLOP (27%). Subjects tended to change their stroke pattern for pushing uphill, with 73% of the subjects choosing the arcing pattern by the 6 degrees grade. No statistically significant differences were found in handrim biomechanics or subject characteristics across stroke pattern groups. CONCLUSIONS: Wheelchair users likely adapt their stroke pattern to accommodate their propulsion environment. Based on the large percentage of subjects who adopted the arcing pattern for pushing uphill, there may be benefits to the arcing pattern for pushing uphill. In light of this and other recent work, it is recommended that clinicians not instruct users to utilize a single stroke pattern in their everyday propulsion environments.

Arch Phys Med Rehabil. 2009 Nov;90(11):1916-23. doi: 10.1016/j.apmr.2009.05.022.

Manual wheelchair propulsion patterns on natural surfaces during start-up propulsion.

Koontz AM, Roche BM, Collinger JL, Cooper RA, Boninger ML. Source Human Engineering Research Laboratories (151R1-H), VA Pittsburgh Health Care System, 7180 Highland Dr., 151R1-H, Pittsburgh, PA 15206, USA. [email protected] Abstract OBJECTIVES: To classify propulsion patterns over surfaces encountered in the natural environment during start-up and compare selected biomechanical variables between pattern types. DESIGN: Case series. SETTING: National Veterans Wheelchair Games, Minneapolis, MN, 2005. PARTICIPANTS: Manual wheelchair users (N=29). INTERVENTION: Subjects pushed their wheelchairs from a resting position over high-pile carpet, over linoleum, and up a ramp with a 5 degrees incline while propulsion kinematics and kinetics were recorded with a motion capture system and an instrumented wheel. MAIN OUTCOME MEASURES: Three raters classified the first 3 strokes as 1 of 4 types on each surface: arc, semicircular (SC), single looping over propulsion (SL), and double looping over propulsion (DL). The Fisher exact test was used to assess pattern changes between strokes and surface type. A multiple analysis of variance test was used to compare peak and average resultant force and moment about the hub, average wheel velocity, stroke frequency, contact angle, and distance traveled between stroke patterns. RESULTS: SL was the most common pattern used during start-up propulsion (44.9%), followed by arc (35.9%), DL (14.1%), and SC (5.1%). Subjects who dropped their hands below the rim during recovery achieved faster velocities and covered greater distances (.016< or =P< or =.075) during start-up on linoleum and carpet and applied more force during start-up on the ramp compared with those who used an arc pattern (P=.066). CONCLUSIONS: Classifying propulsion patterns is a difficult task that should use multiple raters. In addition, propulsion patterns change during start-up, with an arc pattern most prevalent initially. The biomechanical findings in this study agree with current clinical guidelines that recommend training users to drop the hand below the pushrim during recovery. Arch Phys Med Rehabil. 2006 Dec;87(12):1643-7.

Reduced finger and wrist flexor activity during propulsion with a new flexible handrim. Richter WM, Rodriguez R, Woods KR, Karpinski AP, Axelson PW. Source MAX Mobility LLC, Beneficial Designs Inc, Nashville, TN 37211, USA. [email protected] Abstract OBJECTIVE: To test the hypothesis that finger and wrist flexor activity is lower when pushing with a high-friction flexible handrim than with a standard uncoated handrim. DESIGN: Case series. SETTING: Biomechanics laboratory. PARTICIPANTS: Twenty-four manual wheelchair users. INTERVENTION: Subjects pushed their own wheelchairs on a research treadmill set to level, 3 degrees , and 6 degrees grades using both a standard uncoated handrim and a high friction flexible handrim. Propulsion speed was self-selected and held constant between handrim trials. Handrim order was randomized. Finger and wrist flexor muscle activity was measured at the forearm using surface electromyography. MAIN OUTCOME MEASURES: Electromyographic data were rectified and normalized by each subject's maximum voluntary contraction. Total muscle exertion was determined by integrating the rectified signal over each push. Peak and total muscle exertion for each push were averaged across grade conditions and compared across handrims using a repeated measures t test. RESULTS: The flexible handrim resulted in statistically significant reductions in both peak and total forearm muscle activation. Averaging across all subjects and grade conditions, peak muscle activation was reduced by 11.8% (P=.026) and overall muscle exertion was reduced by 14.5% (P=.016). CONCLUSIONS: The flexible handrim was shown to require less finger and wrist flexor activity than a standard uncoated handrim for the same propulsion conditions. PMID: 17141646 [PubMed - indexed for MEDLINE]

Arch Phys Med Rehabil. 2009 Nov;90(11):1904-15. doi: 10.1016/j.apmr.2009.05.023. Comparison of shoulder muscle electromyographic activity during standard manual wheelchair and push-rim activated power assisted wheelchair propulsion in persons with complete tetraplegia. Lighthall-Haubert L, Requejo PS, Mulroy SJ, Newsam CJ, Bontrager E, Gronley JK, Perry J. Source Pathokinesiology Laboratory, Rancho Los Amigos National Rehabilitation Center, 7601 E Imperial Highway, Building 800, Room 33, Downey, CA 90242, USA. [email protected] Abstract OBJECTIVES: To compare spatio-temporal propulsion characteristics and shoulder muscle electromyographic activity in persons with cervical spinal cord injury propelling a standard pushrim wheelchair (WC) and a commercially available pushrim-activated power assisted wheelchair (PAPAW) design on a stationary ergometer. DESIGN: Repeated measures. SETTING: Motion analysis laboratory within a rehabilitation hospital. PARTICIPANTS: Men (N=14) with complete (American Spinal Injury Association grade A or B) tetraplegia (C6=5; C7=9). INTERVENTION: Participants propelled a standard pushrim WC and PAPAW during 3 propulsion conditions: self-selected free and fast and simulated 4% or 8% graded resistance propulsion. MAIN OUTCOME MEASURES: Median speed, cycle length, cadence, median and peak electromyographic activity intensity, and duration of electromyographic activity in pectoralis major, anterior deltoid, supraspinatus, and infraspinatus muscles were compared between standard pushrim WC and PAPAW propulsion. RESULTS: A significant (P<.05) decrease in electromyographic activity intensity and duration of pectoralis major, anterior deltoid, and infraspinatus muscles and significantly reduced intensity and push phase duration of supraspinatus electromyographic activity at faster speeds and with increased resistance were seen during PAPAW propulsion. CONCLUSIONS: For participants with complete tetraplegia, push phase shoulder muscle activity was decreased in the PAPAW compared with standard pushrim WC, indicating a reduction in demands when propelling a PAPAW.

Acta Biomed. 2012 Dec;83(3):177-82.

Prevalence of shoulder discomfort in paraplegic subjects.

Pellegrini A, Pegreffi F, Paladini P, Verdano MA, Ceccarelli F, Porcellini G.

Source
Unit of Shoulder and Elbow surgery, D. Cervesi Hospital, Cattolica (Italy); 2 Orthopedic Clinic, University of Parma, Parma, Italy. [email protected]

Abstract
INTRODUCTION: The annual incidence of acute spinal cord injury, as reported in the National Spinal Cord Injury Statistical Center, was estimated to be approximately 40 cases per million, or approximately 11.000 new cases in the United States each year (1). In subjects with spinal cord injury, overstress of the upper extremities occurs not only during daily life activities, but also utilizing wheelchair. The aim of this study is to determine the prevalence of shoulder discomfort in subjects affected by paraplegia living in our country area and evaluate the associated risk factors negatively affecting the shoulder function. MATERIAL AND METHOD: A computerized database search for paraplegic patients was performed at the Department of Orthopedic Surgery, Trauma Surgery and Rehabilitation Medicine. Among the 54 selected paraplegic patients, 47 accepted to participate at the study. Once the patients were contacted, the medical records were reviewed to obtain information regarding shoulder, elbow and spine region pain and discomfort. RESULTS: The 60% of all the patients who answered to the questionnaire complain shoulder pain, 90% bilaterally, and the 30% referred elbow pain, 20% bilaterally. 77% complains back pain, involving particularly lumbar region. Only 2% of this population undergoes a shoulder surgery treatment for cuff tear and shoulder disability. DISCUSSION AND CONCLUSION: The present study is the first in our country that gives an overview of prevalence of upper limb discomfort in paraplegic patients. We have shown the interplay between shoulder elbow and spine with pain, age of patients and type of wheel chair utilized. The previous factors can be corrected and upper limb discomfort relieved. PMID: 23762992 [PubMed - in process]

Clin Biomech (Bristol, Avon). 2013 Apr;28(4):378-85. doi: 10.1016/j.clinbiomech.2013.03.004. Epub 2013 Apr 19.

A theoretical analysis of the influence of wheelchair seat position on upper extremity demand.
Slowik JS, Neptune RR.

Source
Department of Mechanical Engineering, The University of Texas at Austin, Austin, TX, USA.

Abstract
BACKGROUND: The high physical demands placed on the upper extremity during manual wheelchair propulsion can lead to pain and overuse injuries that further reduce user independence and quality of life. Seat position is an adjustable parameter that can influence the mechanical loads placed on the upper extremity. The purpose of this study was to use a musculoskeletal model and forward dynamics simulations of wheelchair propulsion to identify the optimal seat position that minimizes various measures of upper extremity demand including muscle stress, co-contraction and metabolic cost. METHODS: Forward dynamics simulations of wheelchair propulsion were generated across a range of feasible seat positions by minimizing the change in handrim forces and muscle-produced joint moments. Resulting muscle stress, co-contraction and metabolic cost were examined to determine the optimal seat position that minimized these values. FINDINGS: Muscle stress and metabolic cost were near minimal values at superior/inferior positions corresponding to top-dead-center elbow angles between 110 and 120 while at an anterior/posterior position with a hub-shoulder angle between -10 and -2.5. This coincided with a reduction in the level of muscle co-contraction, primarily at the glenohumeral joint. INTERPRETATION: Deviations from this position lead to increased co-contraction to maintain a stable, smooth propulsive stroke, which consequentially increases upper extremity demand. These results agree with previous clinical guidelines for positioning the seat to reduce upper extremity overuse injuries and pain for wheelchair users. Copyright 2013 Elsevier Ltd. All rights reserved. PMID: 23608478 [PubMed - in process]

Clin Biomech (Bristol, Avon). 2012 Nov;27(9):879-86. doi: 10.1016/j.clinbiomech.2012.07.002. Epub 2012 Jul 24.

The influence of wheelchair propulsion technique on upper extremity muscle demand: a simulation study.
Rankin JW, Kwarciak AM, Richter WM, Neptune RR.

Source
Department of Mechanical Engineering, The University of Texas at Austin, Austin, TX, USA.

Abstract
BACKGROUND: The majority of manual wheelchair users will experience upper extremity injuries or pain, in part due to the high force requirements, repetitive motion and extreme joint postures associated with wheelchair propulsion. Recent studies have identified cadence, contact angle and peak force as important factors for reducing upper extremity demand during propulsion. However, studies often make comparisons between populations (e.g., able-bodied vs. paraplegic) or do not investigate specific measures of upper extremity demand. The purpose of this study was to use a musculoskeletal model and forward dynamics simulations of wheelchair propulsion to investigate how altering cadence, peak force and contact angle influence individual muscle demand. METHODS: Forward dynamics simulations of wheelchair propulsion were generated to emulate group-averaged experimental data during four conditions: 1) self-selected propulsion technique, and while 2) minimizing cadence, 3) maximizing contact angle, and 4) minimizing peak force using biofeedback. Simulations were used to determine individual muscle mechanical power and stress as measures of muscle demand. RESULTS: Minimizing peak force and cadence had the lowest muscle power requirements. However, minimizing peak force increased cadence and recovery power, while minimizing cadence increased average muscle stress. Maximizing contact angle increased muscle stress and had the highest muscle power requirements. INTERPRETATION: Minimizing cadence appears to have the most potential for reducing muscle demand and fatigue, which could decrease upper extremity injuries and pain. However, altering any of these variables to extreme values appears to be less effective; instead small to moderate changes may better reduce overall muscle demand. Copyright 2012 Elsevier Ltd. All rights reserved. PMID: 22835860 [PubMed - indexed for MEDLINE] PMCID: PMC3444526 [Available on 2013/11/1]

Assist Technol. 2013 Spring;25(1):1-8.

Patient safety during assistant propelled wheelchair transfers: the effect of the seat cushion on risk of falling.
Okunribido OO.

Source
Health and Safety Laboratory, Buxton, Derbyshire, United Kingdom. [email protected]

Abstract
This article is a report of a study of the effect of the seat cushion on risk of falling from a wheelchair. Two laboratory studies and simulated assistant propelled wheelchair transfers were conducted with four healthy female participants. For the laboratory studies there were three independent variables: trunk posture (upright/flexed forward), seat cushion (flat polyurethane/propad low profile), and feet condition (dangling/supported), and two dependent variables: occupied wheelchair (wheelchair) center of gravity (CG), and stability. For the simulated transfers there was one independent variable: seat cushion (flat polyurethane/propad low profile), and one dependent variable: perception of safety (risk of falling). Results showed that the wheelchair CG was closer to the front wheels, and stability lower for the propad low profile cushion compared to the polyurethane cushion, when the participants sat with their feet dangling. During the simulated transfers, sitting on the propad low profile cushion caused participants to feel more apprehensive (anxious or uneasy) compared to sitting on the polyurethane cushion. The findings can contribute to the assessment of risk and care planning of nonambulatory wheelchair users. PMID: 23527425 [PubMed - indexed for MEDLINE]

Disabil Rehabil Assist Technol. 2009 Sep;4(5):329-36. doi: 10.1080/17483100902978426.

The effect of shaped wheelchair cushion and lumbar supports on under-seat pressure, comfort, and pelvic rotation.
Samuelsson K, Bjrk M, Erdugan AM, Hansson AK, Rustner B.

Source
Faculty of Health Sciences, Department of Clinical and Experimental Medicine, Rehabilitation Medicine, Linkping, Sweden. [email protected]

Abstract
AIM: A wheelchair seat and position help clients perform daily activities. The comfort of the wheelchair can encourage clients to participate in daily activities and can help prevent future complications. PURPOSE: This study evaluates how a shaped seat-cushion and two different back supports affect under-seat pressure, comfort, and pelvic rotation. METHOD: Thirty healthy subjects were tested using two differently equipped manual wheelchairs. One wheelchair had a Velcro adjustable back seat and a plane seat-cushion. The other wheelchair had a non-adjustable sling-back seat and a plane cushion. The second wheelchair was also equipped with a shaped cushion and/or a detachable lumbar support. Under-seat pressure, estimated comfort, and pelvic rotation were measured after 10 min in each wheelchair outfit. RESULTS: Peak pressure increased with the shaped cushion compared to the plane cushion. No significant difference in estimated comfort was found. Pelvic posterior-rotation was reduced with the adjustable or detachable back-support irrespective of the shape of the seat cushion. CONCLUSIONS: To support a neutral pelvic position and spinal curvature, a combination of a shaped cushion and a marked lumbar support is most effective. PMID: 19565380 [PubMed - indexed for MEDLINE]

IEEE Trans Rehabil Eng. 1996 Dec;4(4):320-7.

Seat cushion design for elderly wheelchair users based on minimization of soft tissue deformation using stiffness and pressure measurements.
Brienza DM, Karg PE, Brubaker CE.

Source
University of Pittsburgh, Department of Rehabilitation Science and Technology, PA 15260, USA.

Abstract
A method for designing seat support surfaces using interface pressure and soft tissue stiffness criteria was evaluated. An algorithm designed to drive a rigid support surface on a programmable seating system to a shape for which the externally applied pressure is inversely related to the measured stiffness of adjacent soft tissue was evaluated on 30 elderly subjects (age 65 years or older). The resulting support surface shapes were transferred to compliant foam cushions and evaluated using interface pressure measurements. Pressure and stiffness measurements on the seating system indicated the surface shape control algorithm met the desired programmed criteria by achieving an inverse relationship between pressure and stiffness, as it converged to an "optimal" support surface shape. Evaluation of interface pressures on the compliant foam cushions showed that the pressure distributions on the cushions contoured to the optimal surface shapes were more uniform and had lower values than distributions on flat foam cushions and foam cushions contoured to shapes measured using state-of-the-art load-deflection devices. The results suggest that support surfaces designed using tissue stiffness as a criteria can provide loading conditions intended to minimize relative deformation and, thus, stress in load-bearing soft tissue. PMID: 8973958 [PubMed - indexed for MEDLINE]

Arch Phys Med Rehabil. 1998 Apr;79(4):388-94. Seat cushion optimization: a comparison of interface pressure and tissue stiffness characteristics for spinal cord injured and elderly patients. Brienza DM, Karg PE. Source Department of Rehabilitation Science and Technology, School of Health and Rehabilitation Sciences, University of Pittsburgh, PA, USA. Abstract OBJECTIVE: A method for designing tissue deformation minimizing seat surfaces was evaluated. Pressure and stiffness criteria were used to optimize surface shape. The method's efficacy for patients with spinal cord injuries (SCI) and a comparison of cushion performance and interface characteristics with a group of 30 elderly patients are presented. DESIGN: Repeated measures, prospective study. SETTING: University medical center. PATIENTS: SCI (n=12), elderly (age 65 + years) [n=30]. INTERVENTIONS: One flat and two custom foam seat cushions. MAIN OUTCOME MEASURES: Interface pressure measured using a pressure sensing pad; tissue stiffness and pressure recorded on a rigid programmable seat surface. RESULTS: Pressure distributions on contoured cushions for the SCI group contained lower values than distributions on flat cushions. A comparison of the pressure data between the elderly and SCI showed that significant differences exist between interface characteristics. The SCI group had higher peak interface pressures for all cushions tested. Tissue stiffness measurements were similar for each group. CONCLUSIONS: Results showed improved effectiveness of custom contoured foam seat cushions versus flat foam cushions. The results suggest that pressure distributions for SCI are more sensitive to support cushion characteristics than for the elderly. Further research is needed to determine the extent of the difference between the populations represented by these groups.

Spine (Phila Pa 1976). 2003 Jun 1;28(11):1113-21; discussion 1121-2. Sitting with adjustable ischial and back supports: biomechanical changes. Makhsous M, Lin F, Hendrix RW, Hepler M, Zhang LQ. Source Sensory Motor Performance Program, Rehabilitation Institute of Chicago, Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois 60611, USA. [email protected] Abstract STUDY DESIGN: The seat and back contact force, pressure distribution, lumbar lordosis, and low back muscle activities associated with a new seat design with adjustable ischial support and backrest were investigated using kinematic, kinetic, electromyographic, and radiographic measurements. OBJECTIVES: To investigate the biomechanical effects of adjusting ischial and backrest supports during sitting. SUMMARY OF THE BACKGROUND DATA: Sitting may induce posterior rotation of the pelvis, reduction of lumbar lordosis, and increases in muscle tension, disc pressure, and pressure on the ischium and coccyx, which may be associated with low back pain. A device that reduces the ischial load and maintains lumbar lordosis may help increase seating comfort and reduce low back pain. METHODS: Fifteen office workers with no known low back pain history were tested. Contact pressure distributions, reaction forces between the buttock-thighs and seat and between the back and backrest, load carried by the seat pan and backrest, sacral inclination, lumbar lordosis, intervertebral space of lumbar spine, and muscular activity in stabilizing the trunk were measured for sitting with and without ischial support and with adjustable back support. RESULTS: When the ischial support was relieved, the center of the force on the seat and on the legs of the chair, and the peak center of pressure on the seat, were significantly (P < 0.002) shifted forward toward the thighs. The total contact area on the seat pan and on the backrest was significantly decreased and increased, respectively (P < 0.001). The sacral inclination, total and segmental lumbar lordosis, and lumbar spine disc height were significantly increased for sitting upright with backrest, with the lumbar curve close to that during standing. CONCLUSIONS: Sitting with reduced ischial support and fitted backrest to the lower spine altered the contact area, reduced peak pressure under the ischia, reduced muscular activity, maintained total and segmental lumbar lordosis, rotated the sacrum forward, and increased lumbar intervertebral disc heights, which could potentially reduce low back pain. PMID: 12782977 [PubMed - indexed for MEDLINE]

Ergonomics. 2003 Apr 15;46(5):518-30.

Free shoulder space requirements in the design of high backrests.

Goossens RH, Snijders CJ, Roelofs GY, van Buchem F.

Source
Erasmus University Rotterdam, Department of Biomedical Physics and Technology, The Netherlands. [email protected]

Abstract
The objective of this study was to determine the influence of scapular support on the effects of lumbar support and to prove that a high and straight backrest is inappropriate. In literature the importance of a lumbar support is noted, although data about optimal dimensions is an under-researched topic and in earlier studies on force distribution and muscle activity the backrest had a fixed form. The lumbar support is needed to maintain the lumbar lordosis but no studies deal with the question of the precise dimensions of the backrest at shoulder level. With a specially designed apparatus, forces on shoulder and seat were measured separately, and the force on the pelvis calculated, while varying seat and backrest inclination within the range from 0 degrees to 17 degrees. Seat-to-backrest angle (at the level of lumbar support) was kept constant at 90 degrees. The distance between the tangent to the lumbar support and the parallel tangent to the scapular support was varied from 0, 2, 4, 6 and 8 cm. This distance is called the free shoulder space. Electromyography was measured at the erector spinae at the levels of the L1, T8 and T5 vertebrae. For all seat angles, a free shoulder space of d=0 cm resulted in the highest back muscle activity. In agreement with the biomechanical model, EMG activity reduced with an increase of seat tilt and increase of free shoulder space. With increasing free shoulder space, a larger part of the total backrest force was carried by the lumbar support. This study shows that a high and straight backrest overrules lumbar support. Offering free shoulder space of at least 6 cm reduces back muscle activity and allows for lumbar support. PMID: 12745700 [PubMed - indexed for MEDLINE]

Am J Occup Ther. 1993 Feb;47(2):141-4.

Clinical evaluation of the Hemi Wheelchair Cushion.

Cron L, Sprigle S.

Source
Neurological Rehabilitation Unit, Augusta Hospital Corporation, Waynesboro, Virginia 22980.

Abstract
A foam cushion was designed for wheelchair users who propel their wheelchairs with the assistance of one lower extremity. It allows users to extend one hip to reach the ground without having to slide forward on the seat, thus maintaining a more erect posture. The cushion was evaluated to identify contraindications for its use. Eleven subjects (10 stroke patients and 1 patient with an above-the-knee amputation) were tested on the Hemi Wheelchair Cushion and on a second cushion chosen by their primary occupational therapists. Seat interface pressures, both before and after dynamic movement, sitting balance, and wheelchair mobility were measured for each cushion. An analysis of mean pressure values revealed no significant difference between the cushion (p = .80). Average pressures after dynamic movement showed a statistically significant difference from pressures before activity (p < .05). Subjective evaluation revealed that the Hemi Wheelchair Cushion did not adversely affect sitting balance or wheelchair mobility, and no contraindications for its use were identified. The results of this clinical evaluation indicate that the Hemi Wheelchair Cushion is an economical and appropriate option for wheelchair users who propel themselves with the assistance of one leg. PMID: 8470743 [PubMed - indexed for MEDLINE]

Send to: Arch Phys Med Rehabil. 2001 Feb;82(2):274-81.

Effect of seat cushion on dynamic stability in sitting during a reaching task in wheelchair users with paraplegia.
Aissaoui R, Boucher C, Bourbonnais D, Lacoste M, Dansereau J.

Source
Dpartement de Gnie Mcanique, Ecole Polytechnique de Montral, Quebec, Canada. [email protected]

Abstract
OBJECTIVES: To examine the effects of seat cushions on dynamic stability in sitting during a controlled reaching task by wheelchair users with paraplegia. DESIGN: A randomized, controlled test. SETTING: Rehabilitation center. PARTICIPANTS: Nine wheelchair users with paraplegia. INTERVENTIONS: Three types of cushions--an air flotation, a generic contoured, and a flat polyurethane foam--were tested during a controlled reaching task in ipsilateral and contralateral directions, at 45 degrees from the sagittal plane in the anterolateral direction. Center of pressure (COP) coordinates were monitored by using a pressure measurement system as well as a force platform under seat. MAIN OUTCOME MEASURES: Trajectory of COP, maximal distance covered by COP, maximal velocity of COP; and the index of asymmetry between right and left maximal pressure under ischial tuberosities. RESULTS: The generic contoured cushion allowed the COP to cover significantly (p <.02) a larger distance (81 +/- 28mm) when compared with the air flotation (63 +/- 25mm) or the flat foam (61 +/- 29mm) cushions. The COP velocity was significant (p <.05) for the generic contoured cushion (.14 +/-.05m/s) versus the air flotation (.10 +/-.04m/s) or the flat-foam (.10 +/-.03m/s) cushions. The index of asymmetry was higher for the generic contoured and the flat foam cushions. During reaching, maximal pressure under ipsilateral ischial tuberosity was significantly higher for the flat foam (275 +/-

70mmHg) and the generic contoured (235 +/- 81mmHg) cushions, when compared with the air flotation cushion (143 +/- 51mmHg). CONCLUSION: Seat cushions can significantly affect sitting balance during reaching tasks. This study provided an objective method to assess the dynamic stability of wheelchair users when they perform activities of daily living requiring reaching. These findings have implications for wheelchair seating recommendations, especially seat cushion selection. PMID: 11239326 [PubMed - indexed for MEDLINE]

2012;2012:4648-51. doi: 10.1109/EMBC.2012.6347003.

Towards an intelligent system for clinical guidance on wheelchair tilt and recline usage.
Fu J, Wiechmann P, Jan YK, Jones M.

Source
University of Central Oklahoma, Edmond, OK 73034, USA. [email protected]

Abstract
We propose to construct an intelligent system for clinical guidance on how to effectively use power wheelchair tilt and recline functions. The motivations fall into the following two aspects. (1) People with spinal cord injury (SCI) are vulnerable to pressure ulcers. SCI can lead to structural and functional changes below the injury level that may predispose individuals to tissue breakdown. As a result, pressure ulcers can significantly affect the quality of life, including pain, infection, altered body image, and even mortality. (2) Clinically, wheelchair power seat function, i.e., tilt and recline, is recommended for relieving sitting-induced pressures. The goal is to increase skin blood flow for the ischemic soft tissues to avoid irreversible damage. Due to variations in the level and completeness of SCI, the effectiveness of using wheelchair tilt and recline to reduce pressure ulcer risks has considerable room for improvement. Our previous study indicated that the blood flow of people with SCI may respond very differently to wheelchair tilt and recline settings. In this study, we propose to use the artificial neural network (ANN) to predict how wheelchair power seat functions affect blood flow response to seating pressure. This is regression learning because the predicted outputs are numerical values. Besides the challenging nature of regression learning, ANN may suffer from the overfitting problem which, when occurring, leads to poor predictive quality (i.e., cannot generalize). We propose using the particle swarm optimization (PSO) algorithm to train ANN to mitigate the impact of overfitting so that ANN can make correct predictions on both existing and new data. Experimental results show that the proposed approach is promising to improve ANN's predictive quality for new data. PMID: 23366964 [PubMed - in process]

J Manipulative Physiol Ther. 2012 Jun;35(5):407-12. doi: 10.1016/j.jmpt.2012.04.015. Epub 2012 May 17.

Association between the side of unilateral shoulder pain and preferred sleeping position: a cross-sectional study of 83 Danish patients.
Kempf B, Kongsted A.

Source
Chiropractor, Chiropractic Clinic, Kerteminde, Denmark.

Abstract
OBJECTIVE: The purpose of this study was to evaluate if there is an association between the side of unilateral shoulder pain and the patient's preferred sleeping position and if the preferred sleeping position is related to which side of a double bed one lies in. METHODS: In a cross-sectional study, adult patients seeking chiropractic care with unilateral shoulder pain were asked about sleeping position and, if sleeping with a partner, which side of the bed they slept in. A total of 83 participants were included from 10 chiropractic clinics. Associations were cross-tabulated and tested by Fisher exact test. RESULTS: The pain was in the right shoulder in 55% (95 % confidence interval, 46-66) of the participants with unilateral pain. The side of shoulder pain was associated to the side patients slept on, with 67% of those sleeping on one side lying on the painful shoulder (P = .02). Moreover, patients were more likely to turn away from their partner at night, and 76% slept on the side opposite their partner (P < .001). CONCLUSIONS: Patients with unilateral shoulder pain were more likely to sleep on the side of the painful shoulder than on the pain-free side and reported to turn away from their partners in bed. It is unknown whether the observed associations are causal, but it is worth investigating whether a change in sleeping position has a positive effect on patients with shoulder pain and if this can be achieved simply by changing side of sleeping in bed. Copyright 2012 National University of Health Sciences. Published by Mosby, Inc. All rights reserved. PMID: 22608285 [PubMed - indexed for MEDLINE]

J Rehabil Med. 2003 Mar;35(2):49-54; quiz 56.

Shoulder pain in hemiplegia revisited: contribution of functional electrical stimulation and other therapies.
Vuagnat H, Chantraine A.

Source
Lox Hospital, University Hospitals of Geneva, Geneva, Switzerland. [email protected]

Abstract
OBJECTIVES: Post-stroke shoulder pain is probably the most frequent complication in hemiplegia and has repercussions on motor rehabilitation and the psychological equilibrium of the patient. The strategies for prevention and treatment are presented. AETIOLOGY: Among the various factors contributing to the occurrence of shoulder pain in hemiplegia, some are related to the joint, such as lesion of the rotator cuff tendons, reflex sympathetic dystrophy, inferior-anterior subluxation of the head of the humerus, whereas others are related to the neurologic lesion such as central post-stroke pain, lack of sensibility, unilateral neglect and spasticity. PREVENTION: Efforts should be made from the start to keep the shoulder in an ideal position at all times and movement of the shoulder and upper limb should be carried out with care. TREATMENT: Will be aimed to the cause of pain and passive or active range of motion exercises will be encouraged. Physical, medical and surgical treatments have improved over the last few decades. Functional electrical stimulation in patients with shoulder pain and subluxation, applied early after onset of the stroke, has shown beneficial positive effects on subluxation, pain and mobility. Efforts should therefore be made to better understand the post-stroke shoulder pain in order to provide better outcomes of rehabilitation and thus improve quality of life for patients.

Spinal Cord. 2012 Aug;50(8):627-31. doi: 10.1038/sc.2012.7. Epub 2012 Feb 21.

Influence of different types of seat cushions on the static sitting posture in individuals with spinal cord injury.
Metring NL, Gaspar MI, Mateus-Vasconcelos EC, Gomes MM, de Abreu DC.

Source
Physiotherapy Course, Department of Biomechanics, Medicine and Rehabilitation of Locomotor System, University of So Paulo, School of Medicine, Ribeiro Preto FMRP-USP, Ribeiro Preto, So Paulo, Brazil.

Abstract
STUDY DESIGN: Cross-sectional study. OBJECTIVES: To evaluate the efficacy of the Postural Assessment Software PAS/SAPO in the posture analysis of individuals with spinal cord injury (SCI) during sitting position and to analyze if the use of different types of seat cushions-gel and foam, with no cushion-can interfere in the individual's posture during sitting position. SETTING: Centre of Rehabilitation at the University Hospital (FMRP-USP), Ribeiro Preto, Brazil. METHODS: Eight individuals, four paraplegics and four tetraplegics with SCI and 20 healthy individuals participated in the study. Photos were taken of individuals in the sitting position using foam, gel cushions and with no cushion. They were analyzed using the PAS/SAPO. The alignment of the anterior-superior iliac spine (ASIS) and the posterior pelvic tilt were evaluated from the angle formed between the ASIS and the greater trochanter of the femur. RESULTS: The group of healthy individuals presented the best postural alignment when compared with the group with SCI, both for the ASIS alignment (P<0.05) and for the degree of posterior pelvic tilt (P<0.05). No significant differences were found in the variables analyzed when the seat cushions were compared. CONCLUSION: The different types of cushions did not alter the sitting posture; however, individuals with SCI showed worse postural alignment than the healthy individuals. PAS/SAPO was demonstrated to be useful for postural assessment. PMID: 22350034 [PubMed - indexed for MEDLINE] Spinal Cord. 2011 Oct;49(10):1055-61. doi: 10.1038/sc.2011.64. Epub 2011 Jul 5.

Clinical and radiographic evaluation of the shoulder of spinal cord injured patients undergoing rehabilitation program.
Medina GI, Nascimento FB, Rimkus CM, Zoppi Filho A, Cliquet A Jr.

Source
Department of Orthopaedic and Traumatology, Faculty of Medical Sciences, State University of Campinas-UNICAMP, Campinas, Brazil. [email protected]

Abstract
STUDY DESIGN: Clinical and radiographic evaluation of the shoulders of tetraplegic and paraplegic patients who attend rehabilitation program. OBJECTIVES: The objective of this study is to establish the usefulness of radiography as a trial exam for shoulder pain in spinal cord injured patients.Setting:Hospital das Clinicas-UNICAMP. Campinas, Sao Paulo, Brazil. METHODS: Thirty-two shoulders of 16 patients were evaluated by clinical exam and radiography. Patients were divided into two groups: paraplegic and tetraplegic. A control group of 16 normal volunteer subjects was selected. RESULTS: Shoulder pain was reported in 88.89% of tetraplegic and 42.85% of paraplegic. The time of injury ranged from 1.5-22 years (mean 7.88 years); patients had a mean age of 34.68 years (range, 21-57 years). The acromioclavicular joint (ACJ) space ranged from 0.03-0.7 cm on the right side and 0.150.7cm on the left side, with a mean of 0.37 and 0.41 cm, respectively. No correlation was found between shoulder pain and gender, age or time since injury. There was a trend to correlation between shoulder pain and type of injury with tetraplegic having a tendency to pain symptoms. On average, tetraplegic had smaller ACJ. CONCLUSIONS: The small number of patients in this study did not allow us to confirm the hypothesis that X-ray finding may indicate risk for shoulder pain in spinal cord injury patients. A work with a greater number of subjects could demonstrate association between shoulder pain and the reduced acromioclavicular distance, making plain radiography a trial exam for spinal cord-injured patients. PMID: 21727901 [PubMed - indexed for MEDLINE]

Spinal Cord. 1998 Mar;36(3):186-9.

Premature degenerative shoulder changes in spinal cord injury patients.

Lal S.

Source
Department of Physical Medicine and Rehabilitation, Northwestern University Medical School, Rehabilitation Institute of Chicago, Illinois 60611, USA.

Abstract
Shoulder pain and the resultant dysfunction is an expected problem in individuals with spinal cord injury. But there is a remarkable lack of information about the natural history, diagnosis, prevention and long term outcomes. Degenerative changes may develop prematurely in their shoulders, due to overuse and altered mechanical stresses, with or without symptoms was the hypothesis of this prospective study. Information from this study is expected to assist in identification of high risk SCI individuals, and ultimately in development of preventive strategies. The shoulders of 53 spinal cord injury patients from the onset of injury until 15 years duration were subjected to clinical and radiological examination at the Rehabilitation Institute of Chicago. Thirty-eight out of 53 (72%) patients demonstrated radiological evidence of degenerative changes, but only six (11%) complained of pain in the shoulders. This study demonstrated a correlation between individuals with higher level of wheelchair activity (72%), higher age (92% above and 8% less than 30 years) and female gender (89% females versus 65% males) more prone to develop degenerative changes in the shoulders. Acromioclavicular joint was predominantly affected. Detailed radiological findings, etiopathological factors and long term recommendations are discussed. The need for further studies and consistent management strategies are stressed. PMID: 9554019 [PubMed - indexed for MEDLINE]

Clin Orthop Relat Res. 1996 Jan;(322):140-5.

Etiologies of shoulder pain in cervical spinal cord injury.

Campbell CC, Koris MJ.

Source
Brigham Orthopedic Associates, Brigham and Women's Hospital, Boston, MA 02115, USA.

Abstract
A protocol including physical examination, plain radiography, and shoulder arthrography was designed to study prospectively the causes of shoulder pain in patients with cervical spinal cord injury. Twenty-four patients (30 shoulders) were studied and subdivided into acute and chronic groups. The causes of shoulder pain in the acute group of 11 patients (15 shoulders) included capsular contracture or capsulitis or both in 6 shoulders; rotator cuff tears in 4; anterior instability in 2; and rotator cuff impingement, osteoarthritis with osteonecrosis, and osteoarthritis in 1 each. Of 13 patients (15 shoulders) assigned to the chronic group, the diagnoses included anterior instability in 5 shoulders; multidirectional instability in 3; capsular contracture or capsulitis or both in 3; and Charcot arthropathy, rotator cuff tear, rotator cuff impingement, and scapular pain in 1 each. To prevent and treat shoulder pain, therapeutic protocols for these patients must be individualized after a correct diagnosis is made. PMID: 8542689 [PubMed - indexed for MEDLINE]

J Shoulder Elbow Surg. 2003 Jul-Aug;12(4):327-32.

Rotator cuff repair in spinal cord injury patients.

Popowitz RL, Zvijac JE, Uribe JW, Hechtman KS, Schrhoff MR, Green JB.

Source
UHZ Sports Medicine Institute, Coral Gables, FL 33146, USA.

Abstract
Previous studies on the treatment of rotator cuff tears in wheelchair-bound patients have concentrated on nonsurgical management. We conducted a retrospective review to determine the effectiveness of surgical repair of rotator cuff tears in spinal cord-injured patients. Five male patients with rotator cuff tears confirmed by physical examination and magnetic resonance imaging underwent rotator cuff repair. Two of eight shoulders were revisions. The patients were evaluated postoperatively with the American Shoulder and Elbow Surgeons Scoring System. These results were compared with preoperative functional assessment. Patients were given a subjective questionnaire to assess their overall experience. Postoperative range of motion improved in 6 of 8 shoulders. Strength was increased in 6 of 8 shoulders. Patients reported satisfaction with the results in 7 of 8 shoulders, and all 5 patients would recommend the procedure to other spinal cord injury patients. At recent follow-up, 7 of 8 shoulders returned to their preinjury level of function. Surgery for spinal cord injury patients with rotator cuff tears can improve their functional capability and autonomy while reducing their pain. Compliance with the demanding postoperative rehabilitation is essential; therefore proper patient selection is crucial for optimal results. PMID: 12934024 [PubMed - indexed for MEDLINE]

Health Technol Assess. 2003;7(29):iii, 1-166.

The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review.
Dinnes J, Loveman E, McIntyre L, Waugh N.

Source
Southampton Health Technology Assessments Centre, University of Southampton, UK.

Abstract
OBJECTIVES: To evaluate the evidence for the effectiveness and cost-effectiveness of the newer diagnostic imaging tests as an addition to clinical examination and patient history for the diagnosis of soft tissue shoulder disorders. DATA SOURCES: Literature was identified from several sources including general medical databases. REVIEW METHODS: Studies were identified that evaluated clinical examination, ultrasound, magnetic resonance imaging (MRI), or magnetic resonance arthrography (MRA) in patients suspected of having soft tissue shoulder disorders. Outcomes assessed were clinical impingement syndrome or rotator cuff tear (full, partial or any). Only cohort studies were included. The methodological quality of included test accuracy studies was assessed using a formal quality assessment tool for diagnostic studies and the extraction of study findings was conducted in duplicate using a pre-designed and piloted data extraction form to avoid any errors. For each test, sensitivity, specificity and positive and negative likelihood ratios with 95% confidence intervals were calculated for each study. Where possible pooled estimates of sensitivity, specificity and likelihood ratios were calculated using random effects methods. Potential sources of heterogeneity were investigated by conducting subgroup analyses. RESULTS: In the included studies, the prevalence of rotator cuff disorders was generally high, partial verification of patients was common and in many cases patients who were selected retrospectively because they had undergone the reference test. Sample sizes were generally very small. Reference tests were often inappropriate with many studies using arthrography alone, despite problems with its sensitivity. For clinical assessment, 10 cohort studies were found that examined either the accuracy of individual tests or clinical examination as a whole: individual tests were either good at ruling out rotator cuff tears when negative (high sensitivity) or at ruling in such disorders when positive (high specificity), but small sample sizes meant that there was no conclusive evidence. Ultrasound was investigated in 38 cohort studies and found to be most accurate when used for the detection of full-thickness tears; sensitivity was lower for detection of partial-thickness tears. For MRI, 29 cohort studies were included. For full-thickness tears, overall pooled sensitivities and specificities were fairly high and the studies were not statistically heterogeneous; however for the detection of partial-thickness rotator cuff tears, the pooled sensitivity estimate was much lower. The results from six MRA studies suggested that it may be very accurate for detection of full-thickness rotator cuff tears, although its performance for the detection of partial-thickness tears was less consistent. Direct evidence for the performance of one test compared with another is very limited.

CONCLUSIONS: The results suggest that clinical examination by specialists can rule out the presence of a rotator cuff tear, and that either MRI or ultrasound could equally be used for detection of full-thickness rotator cuff tears, although ultrasound may be better at picking up partial tears. Ultrasound also may be more cost-effective in a specialist hospital setting for identification of full-thickness tears. Further research suggestions include the need for large, well-designed, prospective studies of the diagnosis of shoulder pain, in particular a follow-up study of patients with shoulder pain in primary care and a prospective cohort study of clinical examination, ultrasound and MRI, alone and/or in combination. PMID: 14567906 [PubMed - indexed for MEDLINE]

BMC Musculoskelet Disord. 2013 Feb 8;14:60. doi: 10.1186/1471-2474-14-60.

Protocol for determining the diagnostic validity of physical examination maneuvers for shoulder pathology.
Somerville L, Bryant D, Willits K, Johnson A.

Source
Health and Rehabilitation Sciences, Faculty of Health Science, Western University, London, Canada.

Abstract
BACKGROUND: Shoulder complaints are the third most common musculoskeletal problem in the general population. There are an abundance of physical examination maneuvers for diagnosing shoulder pathology. The validity of these maneuvers has not been adequately addressed. We propose a large Phase III study to investigate the accuracy of these tests in an orthopaedic setting. METHODS: We will recruit consecutive new shoulder patients who are referred to two tertiary orthopaedic clinics. We will select which physical examination tests to include using a modified Delphi process. The physician will take a thorough history from the patient and indicate their certainty about each possible diagnosis (certain the diagnosis is absent, present or requires further testing). The clinician will only perform the physical examination maneuvers for diagnoses where uncertainty remains. We will consider arthroscopy the reference standard for patients who undergo surgery within 8 months of physical examination and magnetic resonance imaging with arthrogram for patients who do not. We will calculate the sensitivity, specificity and positive and negative likelihood ratios and investigate whether combinations of the top tests provide stronger predictions of the presence or absence of disease. DISCUSSION: There are several considerations when performing a diagnostic study to ensure that the results are applicable in a clinical setting. These include, 1) including a representative sample, 2) selecting an appropriate reference standard, 3) avoiding verification bias, 4) blinding the interpreters of the physical examination tests to the interpretation of the gold standard and, 5) blinding the interpreters of the gold standard to the interpretation of the physical examination tests. The results of this study will inform clinicians of which tests, or combination of tests, successfully reduce diagnostic uncertainty, which tests are misleading and how physical examination may affect the magnitude of the confidence the clinician feels about their diagnosis. The results of this study may reduce the number of costly and invasive imaging studies (MRI, CT or arthrography) that are requisitioned when uncertainty about diagnosis remains following history and physical exam. We also hope to reduce the variability between

specialists in which maneuvers are used during physical examination and how they are used, all of which will assist in improving consistency of care between centres.
PMID: 23394210 [PubMed - indexed for MEDLINE] PMCID: PMC3579687

Eur J Radiol. 2008 Feb;65(2):194-200. doi: 10.1016/j.ejrad.2007.11.012.

The effectiveness of diagnostic imaging methods for the assessment of soft tissue and articular disorders of the shoulder and elbow.
Shahabpour M, Kichouh M, Laridon E, Gielen JL, De Mey J.

Source
Department of Radiology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium. [email protected]

Abstract
There are no clear guidelines for diagnostic imaging of articular and soft tissue pathologies of the shoulder and elbow. Several methods are used, including magnetic resonance imaging (MRI), magnetic resonance arthrography (MRA) and ultrasound (US). Their cost-effectiveness is still unclear. We performed a meta-analysis of the relevant literature and discussed the role of MR imaging of the shoulder and elbow compared with other diagnostic imaging modalities. For the shoulder impingement syndrome and rotator cuff tears, MRI and US have a comparable accuracy for detection of full-thickness rotator cuff tears. MRA and US might be more accurate for the detection of partialthickness tears than MRI. Given the large difference in cost of MR and US, ultrasound may be the most cost-effective diagnostic method for identification of full-thickness tears in a specialist hospital setting (Evidence level 3). Both MRA and CT arthrography (CTA) are effective methods for the detection of labrum tears. More recently, multidetector CTA has offered the advantages of thinner slices than with MRA in a shorter examination time. Still, MRA has the advantage towards CTA to directly visualize the affected structures with a better evaluation of extent and location and to detect associated capsuloligamentous injuries. For the elbow pathologies, plain MRI or MRA have the advantage towards CTA to detect occult bone injuries. CTA is better for the assessment of the thin cartilage of the elbow. Both US and MRI are reliable methods to detect chronic epicondylitis; US is more available and far more cost-effective (Evidence level 2). MRA can differentiate complete from partial tears of the medial collateral ligament. US or MRI can detect partial and complete biceps tendon tears and/or bursitis. MRI can provide important diagnostic information in lesions of the ulnar, radial, or median nerve. PMID: 18312783 [PubMed - indexed for MEDLINE]

Clin Orthop Relat Res. 2002 Oct;(403 Suppl):S26-36.

Shoulder biomechanics and muscle plasticity: implications in spinal cord injury.

Lee TQ, McMahon PJ.

Source
Orthopaedic Biomechanics Laboratory, VA Healthcare System, Long Beach, CA, USA.

Abstract
After spinal cord injury, excessive burden falls on the upper extremity, especially the shoulder. Overall, 51% of persons with spinal cord injury have shoulder problems. Common shoulder problems in persons with spinal cord injury begin with muscle imbalance that can lead to glenohumeral instability, impingement disease, rotator cuff tears, and subsequent degenerative joint disease. These problems can be attributed to the functional demands placed on the shoulder that are specific to patients with spinal cord injury, including overhead activities, wheelchair use, and transfers. Despite preventive exercises, shoulder problems in persons with spinal cord injury remain a significant problem, causing pain and functional limitations. The biomechanics of the shoulder for persons with spinal cord injury resulting from changes in muscle plasticity will be elucidated. Specifically, the effects of scapular protraction that can result from muscle imbalance, the age-dependent properties of the anterior band of the inferior glenohumeral ligament, and the influence of the dynamic restraints around the shoulder will be addressed. PMID: 12394450 [PubMed - indexed for MEDLINE]

J Rehabil Med. 2009 May;41(6):438-44. doi: 10.2340/16501977-0355.

Passive shoulder range of motion impairment in spinal cord injury during and one year after rehabilitation.
Eriks-Hoogland IE, de Groot S, Post MW, van der Woude LH.

Source
Swiss Paraplegic Research, Nottwil, Switzerland. [email protected]

Abstract
OBJECTIVE: To investigate the prevalence and course of pass notive shoulder range of motion in people with a spinal cord injury and the relationships between shoulder range of motion limitations and personal and lesion characteristics. DESIGN: Multicentre longitudinal study. SUBJECTS: A total of 199 subjects with spinal cord injury admitted to specialized rehabilitation centres. METHODS: Assessments of shoulder range of motion at the start of active rehabilitation, 3 months later, at discharge and one year after discharge. RESULTS: Up to 70% (95% confidence interval (CI): 57-81) of the subjects with tetraplegia and 29% (95% CI: 2038) of those with paraplegia experienced a limited range of motion of the shoulder during, or in the first year after, inpatient rehabilitation. Shoulder flexion was affected most. Up to 26% (95% CI: 20-37) of subjects had a shoulder range of motion limitation on both sides. Increased age, tetraplegia, spasticity of elbow extensors and longer duration between injury and start of active rehabilitation increased the risk. Presence of shoulder pain is associated with limited shoulder range of motion. CONCLUSION: Limited shoulder range of motion is common following spinal cord injury. Tetraplegia, increased age, spasticity of elbow extensors, longer duration between injury and start of active rehabilitation and shoulder pain are associated with an increased risk for shoulder range of motion problems and require extra attention. PMID: 19479156 [PubMed - indexed for MEDLINE]

J Rehabil Med. 2011 Feb;43(3):210-5. doi: 10.2340/16501977-0655.

Correlation of shoulder range of motion limitations at discharge with limitations in activities and participation one year later in persons with spinal cord injury.
Eriks-Hoogland IE, de Groot S, Post MW, van der Woude LH.

Source
Swiss Paraplegic Research, CH-6207 Nottwil, Switzerland. [email protected]

Erratum in
J Rehabil Med. 2011 Jun;43(7):660.

Abstract
OBJECTIVE: To study the correlation between limited shoulder range of motion in persons with spinal cord injury at discharge and the performance of activities, wheeling performance, transfers and participation one year later. DESIGN: Multicentre prospective cohort study. SUBJECTS: A total of 146 newly injured subjects with spinal cord injury. METHODS: Shoulder range of motion was measured at discharge. One year later, Functional Independence Measure (FIM), transfer ability, wheelchair circuit and Physical Activity Scale for Individuals with Physical Disabilities (PASIPD) were assessed. Corrections were made for possible confounding factors (age, gender, level and completeness of injury, time since injury and shoulder pain). RESULTS: All subjects with limited shoulder range of motion at discharge had a lower FIM motor score and were less likely (total group 5 times, and subjects with tetraplegia 10 times less likely) to be able to perform an independent transfer one year later. Subjects with limited shoulder range of motion in the total group needed more time to complete the wheelchair circuit. No significant associations with the PASIPD were found in either group. CONCLUSION: Persons with spinal cord injury and limited shoulder range of motion at discharge are more limited in their activities one year later than those without limited shoulder range of motion. PMID: 21305236 [PubMed - indexed for MEDLINE]

Phys Ther. 2011 Mar;91(3):305-24. doi: 10.2522/ptj.20100182. Epub 2011 Feb 3. Strengthening and optimal movements for painful shoulders (STOMPS) in chronic spinal cord injury: a randomized controlled trial. Mulroy SJ, Thompson L, Kemp B, Hatchett PP, Newsam CJ, Lupold DG, Haubert LL, Eberly V, Ge TT, Azen SP, Winstein CJ, Gordon J; Physical Therapy Clinical Research Network (PTClinResNet). Source Pathokinesiology Laboratory, Rancho Los Amigos National Rehabilitation Center, 7601 E Imperial Hwy, Bldg 800, Room 33, Downey, CA 90242, USA. [email protected] Abstract BACKGROUND: Shoulder pain is a common problem after spinal cord injury (SCI), with negative effects on daily activities and quality of life (QOL). OBJECTIVE: The purpose of this study was to determine the effect of an exercise program and instruction to optimize performance of upper-extremity tasks on shoulder pain in people with paraplegia from SCI. METHODS: Design Eighty individuals with paraplegia from SCI and shoulder pain were randomly assigned to receive either an exercise/movement optimization intervention or an attention control intervention. The exercise/movement optimization intervention consisted of a 12-week home-based program of shoulder strengthening and stretching exercises, along with recommendations on how to optimize the movement technique of transfers, raises, and wheelchair propulsion. The attention control group viewed a 1-hour educational video. Outcome measures of shoulder pain, muscle strength (force-generating capacity), activity, and QOL were assessed at baseline, immediately after intervention, and 4 weeks later. RESULTS: Shoulder pain, as measured with the Wheelchair User's Shoulder Pain Index, decreased to one third of baseline levels after the intervention in the exercise/movement optimization group, but remained unchanged in the attention control group. Shoulder torques, most 36-Item Short-Form Health Survey questionnaire (SF-36) subscale scores, and QOL scores also were improved in the exercise/movement optimization group, but not in the attention control group. Improvements were maintained at the 4-week follow-up assessment. Limitations Many of the outcome measures were self-reported, and the participant dropout rate was high in both groups. Additional studies are needed to determine whether the results of this study can be generalized to individuals with tetraplegia. CONCLUSIONS: This home-based intervention was effective in reducing long-standing shoulder pain in people with SCI. The reduction in pain was associated with improvements in muscle strength and health-related and overall QOL. Comment in

PMID:

Strengthening and optimal movements for painful shoulders. [Phys Ther. 2011]

21292803 [PubMed - indexed for MEDLINE]

Med Sci Sports Exerc. 2003 Dec;35(12):1958-61.

Shoulder pain: a comparison of wheelchair athletes and nonathletic wheelchair users.

Fullerton HD, Borckardt JJ, Alfano AP.

Source
Division of Physical Medicine and Rehabilitation, Medical University of South Carolina, Charleston 29425, USA. [email protected]

Abstract
PURPOSE: The purpose of this study was to directly compare the onset and prevalence of shoulder pain in athletic and nonathletic wheelchair users. METHODS: A questionnaire was distributed to athletic and nonathletic wheelchair-dependent populations. This inquired about presence and duration of shoulder pain, age of subject, level of injury, duration of time since injury, wheelchair use, involvement in sports, and training habits. A total of 257 subjects were involved in the study. RESULTS: The odds of having shoulder pain were twice as high among nonathletes as they were among athletes. This finding represents a significant difference over and above age differences, differences in years spent in a wheelchair, and differences in level of spinal cord injury. Athletes also have an average of 12 yr free of shoulder pain after becoming wheelchair bound, whereas nonathletes have only 8 yr. CONCLUSION: Promotion of active exercise for wheelchair users is encouraged to decrease shoulder pain, resulting in more functional, pain-free years. PMID: 14652488 [PubMed - indexed for MEDLINE]

Pediatr Phys Ther. 2008 Fall;20(3):224-32. doi: 10.1097/PEP.0b013e318181162a.

Factors affecting shoulder pain in adolescents and young adults with spina bifida.
Roehrig S, Like G.

Source
Physical Therapy Program, Arkansas State University, State University, Arkansas 72467, USA. [email protected]

Abstract
PURPOSE: This study was designed to determine whether factors affecting shoulder pain in adults with spinal cord injury also affected adolescent and young adult manual wheelchair users with spina bifida. METHODS: Forty-one participants with spina bifida rated their pain using the Wheelchair User's Shoulder Pain Index. RESULTS: Results showed no significant relationship between shoulder pain and age or duration of wheelchair use but significant differences in pain between age groups. Participation in a sports program and level of lesion were not factors in pain intensity. Propelling up an incline was the activity for which the highest intensity of pain was reported. CONCLUSION: Shoulder pain in adolescents and young adults with spina bifida is not as great as previously reported in adults with spinal cord injuries but older subjects had greater pain than younger subjects. PMID: 18703959 [PubMed - indexed for MEDLINE]

Paraplegia. 1995 Oct;33(10):595-601.

Reliability and validity of the Wheelchair User's Shoulder Pain Index (WUSPI).
Curtis KA, Roach KE, Applegate EB, Amar T, Benbow CS, Genecco TD, Gualano J.

Source
Department of Physical Therapy, California State University Fresno 93740-0029, USA.

Abstract
Many long term wheelchair users develop shoulder pain. The purpose of this study was to examine the reliability and validity of the Wheelchair User's Shoulder Pain Index (WUSPI), an instrument which measures shoulder pain associated with the functional activities of wheelchair users. This 15-item functional index was developed to access shoulder pain during transfers, self care, wheelchair mobility and general activities. To establish test-retest reliability, the index was administered twice in the same day to 16 long term wheelchair users and their scores for the two administrations were compared by intraclass correlation. To establish concurrent validity, the index was administered to 64 long term wheelchair users and index scores were compared to shoulder range of motion measurements. Results showed that intraclass correlation for test-retest reliability of the total index score was 0.99. There were statistically significant negative correlations of total index scores to range of motion measurements of shoulder abduction (r = -0.485), flexion (r = -0.479) and shoulder extension (r = -0.304), indicating that there is a significant relationship of total index score to loss of shoulder range of motion in this sample. The Wheelchair User's Shoulder Pain Index shows high levels of reliability and internal consistency, as well as concurrent validity with loss of shoulder range of motion. As a valid and reliable instrument, this tool may be useful to both clinicians and researchers in documenting baseline shoulder dysfunction and for periodic measurement in longitudinal studies of musculoskeletal complications in wheelchair users.

Paraplegia. 1995 May;33(5):290-3.

Development of the Wheelchair User's Shoulder Pain Index (WUSPI).

Curtis KA, Roach KE, Applegate EB, Amar T, Benbow CS, Genecco TD, Gualano J.

Source
Department of Physical Therapy, California State University Fresno 93740-0029, USA.

Abstract
Chronic shoulder pain is a frequently reported phenomenon in individuals who use wheelchairs as their primary means of mobility. No indices are currently available which detect difficulties in performing daily activities due to shoulder discomfort in a largely independent population of wheelchair users. The Wheelchair User's Shoulder Pain Index (WUSPI) was designed to measure shoulder pain in individuals who use wheelchairs. A pilot index was created to measure shoulder pain and related difficulty during basic and instrumental activities of daily living. The instrument was administered to 64 wheelchair users at an athletic event. Analyses of internal consistency and interitem correlations were used to revise and refine the original instrument. Individual item analysis revealed that the subjects in this study experienced the most shoulder pain when wheeling up an incline or on outdoor surfaces, when lifting an object from an overhead shelf, when trying to sleep, when transferring from tub to wheelchair and when washing their backs. The final 15-item index shows high internal consistency. This instrument is useful for both clinical and research purposes to detect and monitor shoulder pain and accompanying loss of function by wheelchair users. PMID: 7630657 [PubMed - indexed for MEDLINE]

Clin Rehabil. 2010 Oct;24(10):867-86. doi: 10.1177/0269215510367981. Epub 2010 Jun 16. A systematic review of wheelchair skills tests for manual wheelchair users with a spinal cord injury: towards a standardized outcome measure. Fliess-Douer O, Vanlandewijck YC, Lubel Manor G, Van Der Woude LH. Source Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, Katholieke Universiteit Leuven, Belgium. [email protected] Abstract OBJECTIVE: To review, analyse, evaluate and critically appraise available wheelchair skill tests in the international literature and to determine the need for a standardized measurement tool of manual wheeled mobility in those with spinal cord injury. DATA SOURCES: A systematic review of literature (databases PubMed, Web of Science and Cochrane Library (1970-December 2009). SUBJECTS: Hand rim wheelchair users, mainly those with spinal cord injury. REVIEW METHODS: Studies' content and methodology were analysed qualitatively. Study quality was assessed using the scale of Gardner and Altman. RESULTS: Thirteen studies fell within the inclusion criteria and were critically reviewed. The 13 studies covered 11 tests, which involved 14 different skills. These 14 skills were categorized into: wheelchair manoeuvring and basic daily living skills; obstacle-negotiating skills; wheelie tasks; and transfers. The Wheelchair Skills Test version 2.4 (WST-2.4) and Wheelchair Circuit tests scored best on the Gardner and Altman scale, the Obstacle Course Assessment of Wheelchair User Performances (OCAWUP) test was found to be the most relevant for daily needs in a wheelchair. The different tests used different measurement scales, varying from binary to ordinal and continuous. Comparison of outcomes between tests was not possible because of differences in skills assessed, measurement scales, environment and equipment selected for each test. A lack of information regarding protocols as well as differences in terminology was also detected. CONCLUSION: This systematic review revealed large inconsistencies among the current available wheelchair skill tests. This makes it difficult to compare study results and to create norms and standards for wheelchair skill performance. Comment in

PMID:

Survey of wheelchair skills tests: making the case for broadening the search and assessment criteria. [Clin Rehabil. 2011]

20554638 [PubMed - indexed for MEDLINE]

J Spinal Cord Med. 2003 Fall;26(3):236-43. Relationships among cushion type, backrest height, seated posture, and reach of wheelchair users with spinal cord injury. Sprigle S, Wootten M, Sawacha Z, Thielman G. Source Research Center for Rehabilitation Technology, Helen Hayes Hospital, West Haverstraw, New York, USA. [email protected] Erratum in

J Spinal Cord Med. 2004;27(3):262. Theilman, Gregory [corrected to Thielman, Gregory].

Abstract BACKGROUND: Seated posture and trunk control are important factors affecting upper extremity (UE) function of wheelchair users. A stable pelvis and trunk are required to provide a base from which UE movement occurs, but, conversely, the ability to move one's trunk and pelvis can increase functional ranges of motion. For wheelchair users, balancing sufficient trunk support with adequate trunk mobility has important functional and medical consequences. OBJECTIVE: To determine the effect of cushion and backrest height on posture and reach and to determine the relationship between posture and UE reach using a randomized 2 x 3 repeated-measures factorial design. METHODS: Twenty-two subjects with spinal cord injury were tested in 6 configurations, including 3 types of cushions (segmented air, contoured viscous fluid/foam, and air/foam) and 2 of 3 backrest heights (referenced to T12, inferior scapular angle, and scapular spine) while performing unilateral and bilateral reaching tasks. Seated posture (pelvic tilt and torso angle) and American Spinal Injury Association (ASIA) score were also measured. RESULTS: Pelvic tilt and ASIA score were significant predictors of reach. No evidence was found indicating cushion type or backrest height affected reach or posture. No consistent patterns of posture were found across cushion types or backrest heights. CONCLUSIONS: The posture adopted by wheelchair users is a more important influence on UE reach than are the cushion or backrest height used. Sitting with increased posterior pelvic tilt enhanced stability and permitted greater reach. Because individuals adopt different postures when using different cushions and backrest heights, clinicians should monitor posture while assessing seating and function of wheelchair users. PMID: 14997965 [PubMed - indexed for MEDLINE]

Scand J Rehabil Med. 1979;11(1):29-32.

Wheelchair user's shoulder? Shoulder pain in patients with spinal cord lesions.
Nichols PJ, Norman PA, Ennis JR.

Abstract
A questionnaire was circulated to the 708 members of the Spinal Cord Injuries Association in 1976. The response rate was 79.5%. Over one half (51.4%) of the respondents suffered from shoulder pain, an incidence in excess of any age group in a control population derived from a general practitioner's register. The pain, which was related particularly to wheelchair usage and other attendant factors such as transfers, was in some instances clearly in the shoulder, whereas in others it was more likely to be cervical root pain. The implication of these findings are discussed. PMID: 419395 [PubMed - indexed for MEDLINE]

J Spinal Cord Med. 2007;30(3):251-5. The relationship of shoulder pain intensity to quality of life, physical activity, and community participation in persons with paraplegia. Gutierrez DD, Thompson L, Kemp B, Mulroy SJ; Physical Therapy Clinical Research Network; Rehabilitation Research and Training Center on Aging-Related Changes in Impairment for Persons Living with Physical Disabilities. Source Pathokinesiology Laboratory, Rancho Los Amigos National Rehabilitation Center, Downey, CA 90242, USA. Abstract BACKGROUND/OBJECTIVE: For persons with spinal cord injury (SCI), severe bodily pain is related to a lower quality of life. However, the effect of pain from a specific body region on quality of life has yet to be determined. The shoulder joint is a common site of pain among persons with SCI. Therefore, our purpose was to identify the relationship of selfreported shoulder pain with quality of life, physical activity, and community activities in persons with paraplegia resulting from SCI. METHODS: Eighty participants with shoulder pain who propel a manual wheelchair (mean age: 44.7 years; mean duration of injury: 20 years; injury level T1-L2) completed the following questionnaires: Wheelchair User's Shoulder Pain Index, Subjective Quality of Life Scale, Physical Activity Scale for Individuals with Physical Disabilities, and Community Activities Checklist. Correlations between shoulder pain scores and quality of life, physical activity, and community activities were determined using Spearman's rho test. RESULTS: Shoulder pain intensity was inversely related to subjective quality of life (r(s) =-0.35; P= 0.002) and physical activity (r(s) = -0.42; P < 0.001). Shoulder pain intensity was not related to involvement in community activities (r(s) = -0.07; P = 0.526). CONCLUSIONS: Persons with SCI who reported lower subjective quality of life and physical activity scores experienced significantly higher levels of shoulder pain. However, shoulder pain intensity did not relate to involvement in general community activities. Attention to and interventions for shoulder pain in persons with SCI may improve their overall quality of life and physical activity. PMID: 17684891 [PubMed - indexed for MEDLINE] PMCID: PMC2031955

Arch Phys Med Rehabil. 2008 Apr;89(4):667-76. doi: 10.1016/j.apmr.2007.09.052. Shoulder biomechanics during the push phase of wheelchair propulsion: a multisite study of persons with paraplegia. Collinger JL, Boninger ML, Koontz AM, Price R, Sisto SA, Tolerico ML, Cooper RA. Source Human Engineering Research Laboratories, VA Rehabilitation Research and Development Center, VA Pittsburgh Healthcare Systems, Pittsburgh, PA 15206, USA. [email protected] Abstract OBJECTIVES: To present a descriptive analysis and comparison of shoulder kinetics and kinematics during wheelchair propulsion at multiple speeds (self-selected and steady-state target speeds) for a large group of manual wheelchair users with paraplegia while also investigating the effect of pain and subject demographics on propulsion. DESIGN: Case series. SETTING: Three biomechanics laboratories at research institutions. PARTICIPANTS: Volunteer sample of 61 persons with paraplegia who use a manual wheelchair for mobility. INTERVENTION: Subjects propelled their own wheelchairs on a dynamometer at 3 speeds (self-selected, 0.9m/s, 1.8m/s) while kinetic and kinematic data were recorded. MAIN OUTCOME MEASURES: Differences in demographics between sites, correlations between subject characteristics, comparison of demographics and biomechanics between persons with and without pain, linear regression using subject characteristics to predict shoulder biomechanics, comparison of biomechanics between speed conditions. RESULTS: Significant increases in shoulder joint loading with increased propulsion velocity were observed. Resultant force increased from 54.4+/-13.5N during the 0.9m/s trial to 75.7+/-20.7N at 1.8m/s (P<.001). Body weight was the primary demographic variable that affected shoulder forces, whereas pain did not affect biomechanics. Peak shoulder joint loading occurs when the arm is extended and internally rotated, which may leave the shoulder at risk for injury. CONCLUSIONS: Body-weight maintenance, as well as other interventions designed to reduce the force required to propel a wheelchair, should be implemented to reduce the prevalence of shoulder pain and injury among manual wheelchair users. PMID: 18373997 [PubMed - indexed for MEDLINE]

J Rehabil Res Dev. 2009;46(7):939-44.

Upper-limb joint kinetics expression during wheelchair propulsion.

Morrow MM, Hurd WJ, Kaufman KR, An KN.

Source
Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA.

Abstract
In the wheelchair propulsion literature, it is common to report upper-limb (UL) joint kinetics to express shoulder, elbow, and wrist loads. Choosing the appropriate kinetic resolution coordinate system (CS) for UL joint forces and moments has become a laboratory-specific process. The differences that arise during interpretation may hinder a clear and broad understanding of UL joint kinetics during wheelchair propulsion. This article addresses the inconsistency of kinetic reporting in the wheelchair literature that examines the pain and injury experienced by manual wheelchair users. To highlight the variety of reporting methods in wheelchair propulsion, this article surveys peer-reviewed, published articles reporting wrist-, elbow-, or shoulder-joint intersegmental forces and moments calculated from inverse dynamics during wheelchair propulsion. To correct this inconsistency, researchers may need to standardize kinetic reporting methods to achieve a cohesive comprehension of wheelchair biomechanics. This article is provided to open discussion on the anatomical and clinical relevance of currently employed CSs and other available options, with the additional goal of providing an initial recommendation for kinetic representation during wheelchair propulsion. PMID: 20104416 [PubMed - indexed for MEDLINE] PMCID: PMC2857327

J Electromyogr Kinesiol. 2010 Feb;20(1):61-7. doi: 10.1016/j.jelekin.2009.02.001. Shoulder demands in manual wheelchair users across a spectrum of activities. Morrow MM, Hurd WJ, Kaufman KR, An KN. Source Mayo Clinic College of Medicine, Department of Orthopedic Research, Mayo Clinic, Guggenheim Building 128, Rochester, MN 55905, USA. Abstract OBJECTIVE: Investigate shoulder joint kinetics over a range of daily activity and mobility tasks associated with manual wheelchair propulsion to characterize demands placed on the shoulder during the daily activity of manual wheelchair users. DESIGN: Case series. SUBJECTS: Twelve individuals who were experienced manual wheelchair users. METHODS: Upper extremity kinematics and handrim wheelchair kinetics were measured over level propulsion, ramp propulsion, start and stop over level terrain, and a weight relief maneuver. Shoulder intersegmental forces and moments were calculated from inverse dynamics for all conditions. RESULTS: Weight relief resulted in significantly higher forces and ramp propulsion resulted in significantly higher moments than the other conditions. Surprisingly, the start condition resulted in large intersegmental moments about the shoulder equivalent with that of the ramp propulsion, while the demand imparted by the stop condition was shown to be equivalent to level propulsion across all forces and moments. CONCLUSIONS: This study provides characterization of daily living and mobility activities associated with manual wheelchair propulsion not previously reported and identifies activities that result in higher shoulder kinetics when compared to standard level propulsion. PMID: 19269194 [PubMed - indexed for MEDLINE] PMCID: PMC2794990 Free PMC Article

Clin Biomech (Bristol, Avon). 2006 Oct;21(8):781-9. Epub 2006 Jun 30.

Shoulder joint kinetics and pathology in manual wheelchair users.

Mercer JL, Boninger M, Koontz A, Ren D, Dyson-Hudson T, Cooper R.

Source
Human Engineering Research Laboratories, 151R1-H, VA Rehabilitation Research and Development Center, VA Pittsburgh Healthcare Systems, 7180 Highland Drive, PA 15206, USA.

Abstract
BACKGROUND: Manual wheelchair users rely heavily on their upper limbs for independent mobility which likely leads to a high prevalence of shoulder pain and injury. The goal of this study was to examine the relationship between shoulder forces and moments experienced during wheelchair propulsion and shoulder pathology. METHODS: Kinetic and kinematic data was recorded from 33 subjects with paraplegia as they propelled their wheelchairs at two speeds (0.9 and 1.8 m/s). Shoulder joint forces and moments were calculated using inverse dynamic methods and shoulder pathology was evaluated using a physical exam and magnetic resonance imaging scan. FINDINGS: Subjects who experienced higher posterior force (Odds Ratio (OR)=1.29, P=0.03), lateral force (OR=1.35, P=0.047), or extension moment (OR=1.35, P=0.09) during propulsion were more likely to exhibit coracoacromial ligament edema. Individuals who displayed larger lateral forces (OR=4.35, P=0.045) or abduction moments (OR=1.58, P=0.06) were more likely to have coracoacromial ligament thickening. Higher superior forces (OR=1.05, P=0.09) and internal rotation moments (OR=1.61 P=0.02) at the shoulder were associated with increased signs of shoulder pathology during the physical exam. INTERPRETATION: Specific joint forces and moments were related to measures of shoulder pathology. This may indicate a need to reduce the overall force required to propel a wheelchair in order to preserve upper limb integrity. Potential interventions include changes to wheelchair setup, propulsion training, or alternative means of mobility. PMID: 16808992 [PubMed - indexed for MEDLINE]

Spinal Cord. 2006 Mar;44(3):152-9.

Upper extremity musculoskeletal pain during and after rehabilitation in wheelchair-using persons with a spinal cord injury.
van Drongelen S, de Groot S, Veeger HE, Angenot EL, Dallmeijer AJ, Post MW, van der Woude LH.

Source
Faculty of Human Movement Sciences, The Institute for Fundamental and Clinical Human Movement Sciences (IFKB), Vrije Universiteit, Amsterdam, The Netherlands.

Abstract
STUDY DESIGN: Prospective cohort study. OBJECTIVES: To study upper extremity musculoskeletal pain during and after rehabilitation in wheelchair-using subjects with a spinal cord injury (SCI) and its relation with lesion characteristics, muscle strength and functional outcome. SETTING: Eight rehabilitation centers with an SCI unit in the Netherlands. METHODS: Using a questionnaire, number, frequency and seriousness of musculoskeletal pain complaints of the upper extremity were measured. A pain score for the wrist, elbow and shoulder joints was calculated by multiplying the seriousness by the frequency of pain complaints. An overall score was obtained by adding the scores of the three joints of both upper extremities. Muscle strength was determined by manual muscle testing. The motor score of the functional independence measure provided a functional outcome. All outcomes were obtained at four test occasions during and 1 year after rehabilitation. RESULTS: Upper extremity pain and shoulder pain decreased over time (30%) during the latter part of in-patient rehabilitation (P<0.001). Subjects with tetraplegia (TP) showed more musculoskeletal pain than subjects with paraplegia (PP) (P<0.001). Upper extremity pain and shoulder pain were significantly inversely related to functional outcome (P<0.001). Muscle strength was significantly inversely related to shoulder pain (P<0.001). Musculoskeletal pain at the beginning of rehabilitation and BMI were strong predictors for pain 1 year after in-patient rehabilitation (P<0.001). CONCLUSIONS: Subjects with TP are at a higher risk for upper extremity musculoskeletal pain and for shoulder pain than subjects with PP. Higher muscle strength and higher functional outcome are related to fewer upper extremity complaints. PMID: 16151450 [PubMed - indexed for MEDLINE]

J Rehabil Res Dev. 2004 Jan-Feb;41(1):65-74.

The effect of rear-wheel position on seating ergonomics and mobility efficiency in wheelchair users with spinal cord injuries: a pilot study.
Samuelsson KA, Tropp H, Nylander E, Gerdle B.

Source
Department of Neuroscience and Locomotion, Section of Rehabilitation Medicine, Faculty of Health Sciences, SE-581 85 Linkping, Sweden. [email protected]

Abstract
This study analyzed the effect of rear-wheel position on seating comfort and mobility efficiency. Twelve randomly selected paraplegic wheelchair users participated in the study. Wheelchairs were tested in two rear-wheel positions while the users operated the wheelchair on a treadmill and while they worked on a computer. Propulsion efficiency, seating comfort, and propulsion qualities were registered at different loads during the treadmill session. During the computer session, pelvic position, estimated seating comfort, and estimated activity performance were measured. The change in rearwheel position affected wheelchair ergonomics with respect to weight distribution (p < 0.0001) and seat inclination angle (position I = 5 and position II = 12). These changes had a significant effect on push frequency (p < 0.05) and stroke angle (p < 0.05) during wheelchair propulsion. We found no consistent effect on mechanical efficiency, estimated exertion, breathlessness, seating comfort, estimated propulsion qualities, pelvic position, or activity performance. PMID: 15273899 [PubMed - indexed for MEDLINE] Free full text

J Rehabil Res Dev. 2004 May;41(3B):403-14.

The effect of seat position on wheelchair propulsion biomechanics.

Kotajarvi BR, Sabick MB, An KN, Zhao KD, Kaufman KR, Basford JR.

Source
Orthopedic Biomechanics Laboratory, Mayo Clinic, Rochester, MN; Motion Analysis Laboratory, Mayo Clinic,Rochester, MN 55905, USA. [email protected]

Abstract
This study examined the effect of seat position on handrim biomechanics. Thirteen experienced users propelled a wheelchair over a smooth level floor at a self-selected speed. Kinetic and temporaldistance data were collected with the use of an instrumented rim and a motion analysis system. A custom-designed axle was used to change the seat position. We used repeated measures analysis of variance to evaluate if differences existed in the temporal-distance and kinetic data with change in seat position. Results showed that a shorter distance between the axle and shoulder (low seat height) improved the push time and push angle temporal variables (p < 0.0001). Tangential force output did not change with seat position. Axial and radial forces were highest in the lowest seat position (p < 0.001). Propulsion efficiency as measured by the fraction of effective force did not significantly change with seat position. PMID: 15543458 [PubMed - indexed for MEDLINE] Free full text

Arch Phys Med Rehabil. 1992 Mar;73(3):263-9.

Biomechanics of wheelchair propulsion as a function of seat position and user-to-chair interface.

Hughes CJ, Weimar WH, Sheth PN, Brubaker CE.

Source
Rehabilitation Engineering Center, University of Virginia, Charlottesville.

Abstract
This study investigated the biomechanics of lever and hand-rim propulsion and the effects of seat position on propulsion mechanics. Nine able-bodied and six paraplegic spinal cord injured persons participated. Subjects performed hand-rim and lever propulsion on a wheelchair test simulator at a speed and load of 3km/hr and 7.5 watts/side, respectively. A 2 x 3 matrix of randomized seat positions was used. Three-dimensional motion measures of the trunk, shoulder, elbow, and wrist were collected over four-second sample periods for each seat position. Hub torque and stroke arc measurements were determined. Upper extremity motions were significantly different (p less than .05) for the two methods of propulsion. Hand-rim propulsion required less elbow motion, greater shoulder extension, less shoulder rotation and less arm abduction than lever propulsion. Both methods of propulsion required a substantial amount of internal rotation at the shoulder. Seat position changes had a greater effect on joint motion ranges when hand-rim propulsion was performed. No significant differences (p greater than .05) were found for trunk motion for the treatments. The findings provide additional information for development of a model for the optimization of wheelchair propulsion. PMID: 1543431 [PubMed - indexed for MEDLINE]

J Rehabil Res Dev. 1989 Fall;26(4):31-50.

Seat height in handrim wheelchair propulsion.

van der Woude LH, Veeger DJ, Rozendal RH, Sargeant TJ.

Source
Faculty of Human Movement Sciences, Free University, Amsterdam, The Netherlands.

Abstract
To study the effect of seat height on the cardiorespiratory system and kinematics in handrim wheelchair ambulation, nine non-wheelchair users participated in a wheelchair exercise experiment on a motor-driven treadmill. The subjects conducted five progressive exercise tests. After an initial tryout test, four tests were performed at different standardized seat heights of 100, 120, 140, and 160 degrees elbow extension (subject sitting erect, hands on the rim in top-dead-center = 12.00 hrs; full extension = 180 degrees). Each test consisted of four 3-minute exercise blocks at speeds of respectively 0.55, 0.83, 1.11, and 1.39 m.s-1 (2-5 km.hr-1). Analysis of variance revealed significant effects of seat height (P less than 0.05) on gross mechanical efficiency (ME), oxygen cost, push range, and push duration, and on the ranges of motion in the different arm segments and trunk. Mean ME appeared higher at the lower seat heights of 100 and 120 degrees elbow extension. This is reflected in an enhanced oxygen consumption at seat heights of 140 and 160 degrees elbow extension. Simultaneously, the push range showed a 15 to 20 degree decrease with increasing seat height, which is reflected in a decreased push duration. In the push phase, decreases in retroflexion and abduction/adduction of the upper arm were seen. The trunk shifted further forward, and the motion range in the elbow joint shifted to extension with increasing seat height. No shifts in minimum and maximum angular velocities were seen with increasing seat height. The results showed an interrelationship between wheelchair seat height and both cardiorespiratory and kinematic parameters. With respect to the cardiorespiratory system, the optimization of the wheelchair geometry, based on functional characteristics of the user, appears beneficial. PMID: 2600867 [PubMed - indexed for MEDLINE]

J Back Musculoskelet Rehabil. 2010;23(2):55-61. doi: 10.3233/BMR-2010-0250.

Shoulder pain: a comparison of wheelchair basketball players with trunk control and without trunk control.
Yildirim NU, Comert E, Ozengin N.

Source
Abant Izzet Baysal University School of Physical Therapy and Rehabilitation, Bolu, Turkey. [email protected]

Abstract
The purpose of this study was to compare shoulder pain between wheelchair basketball players with trunk control and wheelchair basketball players without trunk control. Players were evaluated according the International Wheelchair Basketball Federation (IWBF) classification system. The study group comprised 60 wheelchair basketball players, who were rated according to the International Wheelchair Basketball Federation classification system. Players were divided into two groups according to their trunk control. Study participants completed an anonymous survey that included demographic data, medical history data, and the Wheelchair User's Shoulder Pain Index (WUSPI). There was no statistically significant difference between the two groups based on the number of years of wheelchair use, active sport years, weekly working hours, and weekly training hours (p> 0.05). Statistically significant differences were found between wheelchair basketball players with trunk control and wheelchair basketball players with trunk control with respect to the duration of their disability, the daily number of transfers made to wheelchair, and Performance Corrected Wheelchair User's Shoulder Pain Index (PC-WUSPI) score (p< 0.05). The total PC-WUSPI score was higher among players without trunk control (p< 0.05). Study findings suggest that the shoulder pain of wheelchair basketball players must be analyzed. Trunk stabilization is the key factor affecting the function of the shoulder and is of primary importance for appropriate loading of the shoulder joint's many forms of articulation. PMID: 20555117 [PubMed - indexed for MEDLINE]

J Rehabil Med. 2009 May;41(6):459-66. doi: 10.2340/16501977-0360.

Influence of hand-rim wheelchairs with rear suspension on seat forces and head acceleration during curb descent landings.
Requejo PS, Maneekobkunwong S, McNitt-Gray J, Adkins R, Waters R.

Source
Rehabilitation Engineering Program, Rancho Los Amigos National Rehabilitation Center, 7601 E. Imperial Highway, Building 500, Room 64, Downey, CA, USA. [email protected]

Abstract
OBJECTIVE: Shocks and vibrations experienced while using a hand-rim wheelchair can contribute to discomfort, fatigue and injury. The aim of this study was to compare the seat forces and head accelerations experienced by manual wheelchair users during independent curb descent landings in a standard and 3 suspension-type rigid-frame wheelchairs. DESIGN: Experimental: repeated measures analysis of variance. PARTICIPANTS: Eight men with paraplegia due to spinal cord injury. METHODS: Participants performed independently-controlled curb descent maneuvers with 4 wheelchairs. The seat force and head accelerations were compared across wheelchairs. RESULTS: The suspension-type wheelchairs decreased the seat force and head accelerations by significantly (p < 0.05) extending the force rise time. Also, the seat force and head accelerations were inversely related to the seat force at initial contact. The monoshock-based suspension wheelchairs showed the least seat force and longest force rise time. CONCLUSION: Suspension systems result in softer landings by attenuating the magnitude and time duration of the force and reducing head accelerations. Hand-rim wheelchair users can also soften landings by utilizing a "pull-up" strategy that reduces the force and head accelerations. Softer landings can contribute to improved ride quality. PMID: 19479159 [PubMed - indexed for MEDLINE] Free full text

Arch Phys Med Rehabil. 2003 Jan;84(1):96-102.

Seat and footrest shocks and vibrations in manual wheelchairs with and without suspension.
Cooper RA, Wolf E, Fitzgerald SG, Boninger ML, Ulerich R, Ammer WA.

Source
Department of Rehabilitation Science & Technology and Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA. [email protected]

Abstract
OBJECTIVE: To examine differences in the shock and vibration transmitted to an occupant of a manual wheelchair with and without suspension caster forks and with and without rear-suspension systems. DESIGN: Repeated-measures engineering testing. SETTING: Rehabilitation engineering center with a wheelchair standards test laboratory. SPECIMENS: Six manual wheelchairs. INTERVENTIONS: An American National Standards Institute/Rehabilitation Engineering and Assistive Technology Society of North America wheelchair test dummy and a Hybrid III test dummy were used to test shock and vibration transmission in wheelchairs equipped with original equipment manufacturer (OEM) caster forks and suspension caster forks. Ultralight wheelchairs, half of which had factory-equipped rear-suspension systems, were tested. Testing was conducted on a double-drum wheelchair test machine. MAIN OUTCOME MEASURES: Shocks were examined by using peak acceleration and the frequency at which peak acceleration occurs for the seat and footrest. Vibration was characterized by the acceleration power per octave for the seat and footrest. RESULTS: Significant differences were found in the peak accelerations at the seat (P=.0004) and footrest (P=.0007) between the wheelchairs with the OEM caster forks and those with the suspension casters. The wheelchairs with suspension had significantly different frequencies at which the peak accelerations occurred for both the seat (P=.01) and footrest (P=.0001). The wheelchairs with suspension caster forks had a lower total power per octave than the wheelchairs with the OEM caster forks. For the footrest vibrations, significant differences were found between the types of caster forks

for all octaves except those associated with frequencies more than 78.75Hz. There were significant differences for wheelchairs with and without rear suspension for total power per octave of seat vibrations in the octaves between 7.81 and 9.84Hz (P=.01) and 12.40 and 15.63Hz (P=.008). CONCLUSIONS: Suspension caster forks reduce the shock and vibration exposure to the user of a manual wheelchair. Rear-suspension systems reduce some of the factors related to shock and vibration exposure, but they are not clearly superior to traditional designs. Copyright 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. PMID: 12589628 [PubMed - indexed for MEDLINE]

Spinal Cord. 2008 May;46(5):335-43. Epub 2007 Nov 20.

Comparative shoulder kinematics during free standing, standing depression lifts and daily functional activities in persons with paraplegia: considerations for shoulder health.
Riek LM, Ludewig PM, Nawoczenski DA.

Source
Department of Physical Therapy, Ithaca College, Rochester Center, Rochester, NY 14620, USA.

Abstract
STUDY DESIGN: Case series; nonparametric repeated-measures analysis of variance. OBJECTIVE: To compare and contrast three-dimensional shoulder kinematics during frequently utilized upper extremity weight-bearing activities (standing depression lifts used in brace walking, weight-relief raises, transfers) and postures (sitting rest, standing in a frame) in spinal cord injury (SCI). SETTING: Movement Analysis Laboratory, Department of Physical Therapy, Ithaca College, Rochester, NY, USA. METHODS: Three female and two male subjects (39.2+/-6.1 years old) at least 12 months post-SCI (14.6+/-6.7 years old), SCI distal to T2 and with an ASIA score of A. The Flock of Birds magnetic tracking device was used to measure three-dimensional positions of the scapula, humerus and thorax during various activities. RESULTS: Standing in a frame resulted in significantly less scapular anterior tilt (AT) and greater glenohumeral external rotation (GHER) than standing depression lifts and weight-relief raises. CONCLUSIONS: Standing frame posture offers the most favorable shoulder joint positions (less scapular AT and greater GHER) when compared to sitting rest posture, weight-relief raises, transfers and standing depression lifts. Knowledge of kinematic patterns associated with each activity is an essential first step to understanding the potential impact on shoulder health. Choosing specific activities or modifying techniques within functional activities that promote favorable shoulder positions may preserve long-term shoulder health. PMID: 18026174 [PubMed - indexed for MEDLINE]

J Rehabil Med. 2011 Feb;43(3):210-5. doi: 10.2340/16501977-0655. Correlation of shoulder range of motion limitations at discharge with limitations in activities and participation one year later in persons with spinal cord injury. Eriks-Hoogland IE, de Groot S, Post MW, van der Woude LH. Source Swiss Paraplegic Research, CH-6207 Nottwil, Switzerland. [email protected] Erratum in J Rehabil Med. 2011 Jun;43(7):660.

Abstract OBJECTIVE: To study the correlation between limited shoulder range of motion in persons with spinal cord injury at discharge and the performance of activities, wheeling performance, transfers and participation one year later. DESIGN: Multicentre prospective cohort study. SUBJECTS: A total of 146 newly injured subjects with spinal cord injury. METHODS: Shoulder range of motion was measured at discharge. One year later, Functional Independence Measure (FIM), transfer ability, wheelchair circuit and Physical Activity Scale for Individuals with Physical Disabilities (PASIPD) were assessed. Corrections were made for possible confounding factors (age, gender, level and completeness of injury, time since injury and shoulder pain). RESULTS: All subjects with limited shoulder range of motion at discharge had a lower FIM motor score and were less likely (total group 5 times, and subjects with tetraplegia 10 times less likely) to be able to perform an independent transfer one year later. Subjects with limited shoulder range of motion in the total group needed more time to complete the wheelchair circuit. No significant associations with the PASIPD were found in either group. CONCLUSION: Persons with spinal cord injury and limited shoulder range of motion at discharge are more limited in their activities one year later than those without limited shoulder range of motion. PMID: 21305236 [PubMed - indexed for MEDLINE] Free full text

J Rehabil Med. 2009 Feb;41(3):143-9. doi: 10.2340/16501977-0296.

Seat height: effects on submaximal hand rim wheelchair performance during spinal cord injury rehabilitation.
van der Woude LH, Bouw A, van Wegen J, van As H, Veeger D, de Groot S.

Source
Research Institute MOVE, Institute for Fundamental and Clinical Human Movement Sciences, Faculty of Human Movement Sciences, VU University, Amsterdam, The Netherlands. [email protected]

Abstract
OBJECTIVE: To evaluate the effects of wheelchair seat height on wheeling efficiency and technique during rehabilitation in subjects with a spinal cord injury. DESIGN: Laboratory-based study. SUBJECTS: Twelve persons with spinal cord injury (age range 19-77 years, lesion level: C5/C6-L2; 7 men; 8 incomplete). METHODS: Subjects conducted 8 submaximal hand rim wheelchair exercise tests (4 min) on a computerized ergometer at 8 seat heights (elbow angle: 70-140 degrees , full extension = 180 degrees) in a counter-balanced order (individualized fixed power output (5.4-13.9 W) and speed). Last-minute physiological and technique parameters were evaluated using repeated measures analysis of variance (ANOVA) and multilevel regression analysis (p < 0.05). RESULTS: Physical strain and mechanical efficiency changed significantly (p < 0.05) with seat height, with optimal values at 100-130 degrees . Lower seat heights were clearly detrimental. Forces on the hand rims were affected by seat height, showing lower forces with increasing seat height. Lesion level was not a confounder of seat height with respect to mechanical efficiency, oxygen uptake or fraction effective force. CONCLUSION: Mean physiological data indicate a tendency to optimize at 100-130 degrees seat height. This does not relate to the trends seen in force and technique data. Optimization of seat height during spinal cord injury rehabilitation may lead to more efficient and less straining conditions for manual wheeling. PMID: 19229446 [PubMed - indexed for MEDLINE] Free full text

Arch Phys Med Rehabil. 2007 Dec;88(12):1727-9. Arm crank ergometry and shoulder pain in persons with spinal cord injury. Dyson-Hudson TA, Sisto SA, Bond Q, Emmons R, Kirshblum SC. Source Kessler Medical Rehabilitation Research and Education Center, West Orange, NJ 07052, USA. [email protected] Abstract OBJECTIVE: To determine whether a primary fitness program utilizing arm crank ergometry would cause increased shoulder pain in persons with spinal cord injury (SCI). DESIGN: Cohort study. SETTING: Clinical research center. PARTICIPANTS: People (N=23) with chronic SCI (>1 y) who were participating in a weight loss study to compare the effectiveness of diet only (1000 kcal/d for 12 wk) versus diet with arm crank ergometry (1000 kcal/d and arm crank ergometry 3 times a week for 12 wk). INTERVENTION: Arm crank ergometry. MAIN OUTCOME MEASURE: Changes in shoulder pain intensity using the Wheelchair User's Shoulder Pain Index (WUSPI). RESULTS: After adjusting for baseline scores, there was no significant difference between the 2 groups on postintervention WUSPI scores (F(1,20)=.85, P=.37, partial eta2=.04). The strength of the relationship between group assignment (diet only vs diet and arm crank ergometry) and final WUSPI score was weak, as assessed by a partial eta2, with group assignment accounting for 4% of the variance on the WUSPI. The adjusted means were lower in the diet and arm crank ergometry group (mean, 7.84) than in the diet only group (mean, 12.22); however, these differences did not appear to be clinically significant. CONCLUSIONS: A primary fitness program using arm crank ergometry does not increase shoulder pain in people with SCI who use wheelchairs. Further investigation with a larger group and what constitutes clinically significant changes on the WUSPI is warranted to confirm our results. PMID: 18047893 [PubMed - indexed for MEDLINE]

Clin Biomech (Bristol, Avon). 2010 May;25(4):299-306. doi: 10.1016/j.clinbiomech.2009.12.011. Epub 2010 Jan 27.

Upper limb joint dynamics during manual wheelchair propulsion.

Desroches G, Dumas R, Pradon D, Vaslin P, Lepoutre FX, Chze L.

Source
Universit de Lyon, Universit Lyon 1, Villeurbanne F-69622, France. [email protected]

Abstract
BACKGROUND: Inverse dynamic methods have been widely used to estimate joint loads during manual wheelchair propulsion. However, the interpretation of 3D net joint moments and powers is not always straightforward. It has been suggested to use joint coordinate systems (expression of joint moment on anatomical axes) and the 3D angle between joint moment and angular velocity vectors (propulsion, resistance or stabilization joint configuration) for a better understanding of joint dynamics. METHODS: Nine spinal cord injured subjects equipped with reflective markers propelled in a wheelchair with an instrumented wheel. Inverse dynamic results were interpreted using joint coordinate systems, 3D joint power and the 3D angle between the joint moment and joint angular velocity vectors at the three upper limb joints. The 3D angle was used to determine if the joints were predominantly driven (angle close to 0 or 180 degrees) or stabilized (angle close to 90 degrees ). FINDINGS: The wrist and elbow joints are mainly in a stabilization configuration (angle close to 90 degrees ) with a combination of extension and ulnar deviation moments and an adduction moment respectively. The shoulder is in a propulsion configuration, but close to stabilization (angle hardly below 60 degrees ) with a combination of flexion and internal rotation moments. INTERPRETATION: Stabilization configuration at the joints could partly explain the low mechanical efficiency of manual wheelchair propulsion and could give insight about injury risk at the wrist, elbow and shoulder joints. Copyright 2009 Elsevier Ltd. All rights reserved. PMID: 20106573 [PubMed - indexed for MEDLINE]

J Biomech. 2010 Sep 17;43(13):2508-15. doi: 10.1016/j.jbiomech.2010.05.021. Epub 2010 Jun 11.

Upper limb joint kinetics during manual wheelchair propulsion in patients with different levels of spinal cord injury.
Gil-Agudo A, Del Ama-Espinosa A, Prez-Rizo E, Prez-Nombela S, Pablo Rodrguez-Rodrguez L.

Source
Biomechanics and Technical Aids Unit, Physical Medicine and Rehabilitation Department, National Hospital for Spinal Cord Injury, SESCAM, Toledo, Spain. [email protected]

Abstract
The purpose of this study was to compare the forces and moments of the whole upper limb, analyzing forces and moments at the shoulder, elbow and wrist joints simultaneously during manual wheelchair propulsion of persons with different levels of spinal cord injury (SCI) on a treadmill. Fifty-one people participated in this study and were grouped by their level of SCI: C6 tetraplegia (G1), C7 tetraplegia (G2), high paraplegia (G3), and low paraplegia (G4). An inverse dynamic model was defined to compute net joint forces and moments from segment kinematics, the forces acting on the pushrim, and subject anthropometrics. Right side, upper limb kinematic data were collected with four camcorders (Kinescan-IBV). Kinetic data were recorded by replacing the wheels with SmartWheels (Three Rivers Holdings, LLC). All participants propelled the wheelchair at 3km/h for 1min. The most noteworthy findings in both our tetraplegic groups in relation to paraplegic groups were increased superior joint forces in the shoulder (G1 and G2 vs G3 p<0.001; G1 and G2 vs G4 p<0.01), elbow (G1 vs G3 p<0.001; G1 vs G4 p<0.05) and wrist (G1 vs G4 p<0.001), an increased adduction moment in the shoulder (G1 vs G3 p<0.001; G1 vs G4 p<0.01; G2 vs G3 and G4 p<0.05) and the constancy of the moments of force of the wrist the fact that they reached their lowest values in the tetraplegic groups. This pattern may increase the risk of developing upper limb overuse injuries in tetraplegic subjects. PMID: 20541760 [PubMed - indexed for MEDLINE]

Clin Biomech (Bristol, Avon). 2001 Nov;16(9):744-51.

The effect of level of spinal cord injury on shoulder joint kinetics during manual wheelchair propulsion.
Kulig K, Newsam CJ, Mulroy SJ, Rao S, Gronley JK, Bontrager EL, Perry J.

Source
Pathokinesiology Laboratory, Rancho Los Amigos National Rehabilitation Center, 7601 E. Imperial Hwy., Downey, CA 90242, USA. [email protected]

Abstract
OBJECTIVE: The effects of spinal cord injury level on shoulder kinetics during manual wheelchair propulsion were studied. DESIGN: Single session data collection in a laboratory environment. METHODS: Male subjects were divided into four groups: low level paraplegia (n=17), high level paraplegia (n=19), C7 tetraplegia (C7, n=16) and C6 tetraplegia (C6, n=17). Measurements were recorded using a sixcamera VICON motion analysis system, a strain gauge instrumented wheel, and wheelchair ergometer. Shoulder joint forces and moments were calculated using the inverse dynamics approach. RESULTS: Mean self-selected propulsion velocity was higher in the paraplegic (low paraplegia=90.7 m/min; high paraplegia=83.4 m/min) than tetraplegic (C7=66.5 m/min; C6=47.0 m/min) groups. After covarying for velocity, no significant differences in shoulder joint moments were identified. However, superior push force in subjects with tetraplegia (C7=21.4 N; C6=9.3 N) was significantly higher than in those with high paraplegia (7.3 N), after covarying velocity. CONCLUSIONS: The superior push force in the tetraplegic groups coupled with weakness of thoraco-humeral depressors increases susceptibility of the subacromial structures to compression. RELEVANCE: Increased vertical force at the shoulder joint, coupled with reduced shoulder depressor strength, may contribute to shoulder problems in subjects with tetraplegia. Wheelchair design modifications, combined with strength and endurance retention, should be considered to prevent shoulder pain development. PMID: 11714551 [PubMed - indexed for MEDLINE]

Gait Posture. 1999 Dec;10(3):223-32.

Three dimensional upper extremity motion during manual wheelchair propulsion in men with different levels of spinal cord injury.
Newsam CJ, Rao SS, Mulroy SJ, Gronley JK, Bontrager EL, Perry J.

Source
Rancho Los Amigos Medical Center, Pathokinesiology Laboratory, Building 800 Room 33, 7601 E. Imperial Highway, Downey, CA 90242, USA.

Abstract
This investigation compared three dimensional upper extremity motion during wheelchair propulsion in persons with 4 levels of spinal cord injury: low paraplegia (n=17), high paraplegia (n=19), C7 tetraplegia (n=16), and C6 tetraplegia (n=17). Upper extremity motion was recorded as subjects manually propelled a wheelchair mounted on a stationary ergometer. For all motions measured, subjects with paraplegia had similar patterns suggesting that the wheelchair backrest adequately stabilizes the trunk in the absence of abdominal musculature. Compared with paraplegic subjects, those with tetraplegia differed primarily in the strategy used to contact the wheel. This was most evident among subjects with C6 tetraplegia who had greater wrist extension and less forearm pronation. PMID: 10567754 [PubMed - indexed for MEDLINE]

IEEE Trans Rehabil Eng. 1996 Dec;4(4):403-9.

Measurement of isometric elbow and shoulder moments: positiondependent strength of posterior deltoid-to-triceps muscle tendon transfer in tetraplegia.
Kirsch RF, Acosta AM, Perreault EJ, Keith MW.

Source
Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH 44109, USA.

Abstract
This report describes an apparatus which has been developed to measure several isometric elbow and shoulder forces and moments simultaneously and also allows this characterization to be performed across a range of shoulder and elbow joint angles in a horizontal plane. This apparatus was used to characterize the elbow extension strength in individuals with tetraplegia resulting from cervical level spinal cord injury. In all of these individuals, voluntary elbow extension was provided exclusively by the posterior deltoid muscle, which had previously been surgically transferred to the tendon of the paralyzed triceps muscle. Elbow extension is essential for many daily activities, such as reaching above shoulder level and pushing objects away from the body; the widely used posterior deltoid-to-triceps muscle tendon transfer surgery restores some degree of voluntary control to this important function. The apparatus contained a six-axis force-moment transducer to which the arm of each subject was attached. The six outputs of the transducer were transformed to correspond to physiological elbow and shoulder moments and forces. A customized table allowed the shoulder and elbow angles of the subject to be varied over a wide range in a horizontal plane so that the effects of posterior deltoid muscle length could be characterized over the likely functional range of the subject within this plane. It was found that elbow extension strength varied widely across subjects with C5 or C6 tetraplegia, from quite weak to strong enough to propel a manual wheelchair. Furthermore, the elbow extension strength of most subjects showed a strong dependence on both elbow and shoulder angles. Elbow extension was typically weak when the upper arm was elevated to shoulder level at the side, which unfortunately corresponds to the position often adopted by these individuals due to shoulder weakness. PMID: 8973966 [PubMed - indexed for MEDLINE]

PM R. 2010 Oct;2(10):896-900. doi: 10.1016/j.pmrj.2010.05.004. Association of shoulder pain with the use of mobility devices in persons with chronic spinal cord injury. Jain NB, Higgins LD, Katz JN, Garshick E. Source Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, 125 Nashua St, Boston, MA 02114, USA. [email protected] Abstract OBJECTIVE: To assess the prevalence of shoulder pain and its association with the use of assistive devices for mobility in persons with chronic spinal cord injury (SCI). DESIGN: Cross-sectional analysis conducted within a cohort study. SETTING: SCI service in a hospital and the community. PARTICIPANTS: Between August 2005 and January 2008, 93 participants with chronic SCI completed a standardized health questionnaire and pain questionnaire. MAIN OUTCOME MEASURES: Shoulder pain in last 6 months elicited by use of the McGill Pain Questionnaire pain diagram. RESULTS: Of the 93 participants, 65 (69.9%) reported pain at any site in the 6 months before testing. Shoulder pain, reported by 39.8% of participants, was the third most common site of pain after the legs and back. When stratified by the use of assistive mobility devices, shoulder pain was reported by 46.7% of motorized wheelchair users, 35.4% of manual wheelchair users, 47.6% of participants using aids such as crutch(es) or canes, and 33.3% of participants walking without assistance (P = .7 for comparison of 4 groups). CONCLUSIONS: Shoulder pain is highly prevalent in SCI. The authors of previous studies have largely attributed shoulder pain in SCI to manual wheelchair use. However, our results provide evidence for similarly elevated prevalence of shoulder pain among motorized wheelchair users and those patients using crutches or canes. This finding suggests that in addition to overuse injury from cyclic wheelchair

propulsion, the assessment of other mechanical and nonmechanical factors that lead to shoulder pain in SCI is an unmet research need that may have treatment implications. Copyright 2010 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved. PMID: 20970758 [PubMed - indexed for MEDLINE] PMCID: PMC3078578 Free PMC Article

Phys Med Rehabil Clin N Am. 2010 Feb;21(1):1-13. doi: 10.1016/j.pmr.2009.07.004.

Quality-of-life technology for people with spinal cord injuries.

Cooper RA, Cooper R.

Source
Human Engineering Research Laboratories, Pittsburgh VA Rehabilitation Research & Development Center, VA Pittsburgh Healthcare System, 7180 Highland Drive, Pittsburgh, PA 15206, USA. [email protected]

Abstract
Technology plays a critical role in promoting well-being, activity, and participation for individuals with spinal cord injury (SCI). As technology has improved, so has the realm of possibilities open to people with SCI. School, work, travel, and leisure activities are all facilitated by technology. Advances in materials have made wheelchairs lighter, and developments in design have made wheelchairs that fit individual needs. Software has made computer interfaces adaptive and in some case intelligent, through learning the user's behavior and optimizing its structure. As participatory action design and aware systems take greater hold, transformational change is likely to take place in the technology available to people with SCI. PMID: 19951774 [PubMed - indexed for MEDLINE]

Arch Phys Med Rehabil. 2004 Nov;85(11):1859-64.

Demographic and socioeconomic factors associated with disparity in wheelchair customizability among people with traumatic spinal cord injury.
Hunt PC, Boninger ML, Cooper RA, Zafonte RD, Fitzgerald SG, Schmeler MR.

Source
Human Engineering Research Laboratories, Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, PA, USA.

Abstract
OBJECTIVES: To determine if a standard of care for wheelchair provision exists within the participating centers and if there is disparity in wheelchair customizability among the study sample. DESIGN: Convenience sample survey. SETTING: Thirteen Model Spinal Cord Injury Systems that provide comprehensive rehabilitation for people with traumatic spinal cord injury (SCI) and that are part of the national database funded through the US Department of Education. PARTICIPANTS: A total of 412 people with SCI who use wheelchairs over 40 hours a week. INTERVENTION: Survey information was obtained from subjects via telephone and in-person interviews and from the national database. Collected information included age, race, education, level of injury, and wheelchair funding source. MAIN OUTCOME MEASURES: Number and type (manual or power) of wheelchairs. Wheelchair customizability as defined by design features (eg, adjustable axle position, programmable controls). RESULTS: Ninety-seven percent of manual wheelchair users and 54% of power wheelchair users had customizable wheelchairs. No power wheelchair user received a wheelchair without programmable controls. Minorities with low socioeconomic backgrounds (low income, Medicaid/Medicare recipients, less educated) were more likely to have standard manual and standard programmable power wheelchairs. Older subjects were also more likely to have standard programmable power wheelchairs.

CONCLUSIONS: The standard of care for manual wheelchair users with SCI is a lightweight and customizable wheelchair. The standard of care for power wheelchairs users has programmable controls. Unfortunately, socioeconomically disadvantaged people were less likely to receive customizable wheelchairs. PMID: 15520982 [PubMed - indexed for MEDLINE]

Arch Phys Med Rehabil. 2004 Nov;85(11):1859-64. Demographic and socioeconomic factors associated with disparity in wheelchair customizability among people with traumatic spinal cord injury. Hunt PC, Boninger ML, Cooper RA, Zafonte RD, Fitzgerald SG, Schmeler MR. Source Human Engineering Research Laboratories, Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, PA, USA. Abstract OBJECTIVES: To determine if a standard of care for wheelchair provision exists within the participating centers and if there is disparity in wheelchair customizability among the study sample. DESIGN: Convenience sample survey. SETTING: Thirteen Model Spinal Cord Injury Systems that provide comprehensive rehabilitation for people with traumatic spinal cord injury (SCI) and that are part of the national database funded through the US Department of Education. PARTICIPANTS: A total of 412 people with SCI who use wheelchairs over 40 hours a week. INTERVENTION: Survey information was obtained from subjects via telephone and in-person interviews and from the national database. Collected information included age, race, education, level of injury, and wheelchair funding source. MAIN OUTCOME MEASURES: Number and type (manual or power) of wheelchairs. Wheelchair customizability as defined by design features (eg, adjustable axle position, programmable controls). RESULTS: Ninety-seven percent of manual wheelchair users and 54% of power wheelchair users had customizable wheelchairs. No power wheelchair user received a wheelchair without programmable controls. Minorities with low socioeconomic backgrounds (low income, Medicaid/Medicare recipients, less educated) were more likely to have standard manual and standard programmable power wheelchairs. Older subjects were also more likely to have standard programmable power wheelchairs. CONCLUSIONS: The standard of care for manual wheelchair users with SCI is a lightweight and customizable wheelchair. The standard of care for power wheelchairs users has programmable controls. Unfortunately, socioeconomically disadvantaged people were less likely to receive customizable wheelchairs. PMID: 15520982 [PubMed - indexed for MEDLINE]

J Rehabil Res Dev. 2008;45(1):53-71.

How many people would benefit from a smart wheelchair?

Simpson RC, LoPresti EF, Cooper RA.

Source
Department of Rehabilitation Sciences and Technology, University of Pittsburgh, Pittsburgh, PA 15238-2887, USA. [email protected]

Abstract
Independent mobility is important, but some wheelchair users find operating existing manual or powered wheelchairs difficult or impossible. Challenges to safe, independent wheelchair use can result from various overlapping physical, perceptual, or cognitive symptoms of diagnoses such as spinal cord injury, cerebrovascular accident, multiple sclerosis, amyotrophic lateral sclerosis, and cerebral palsy. Persons with different symptom combinations can benefit from different types of assistance from a smart wheelchair and different wheelchair form factors. The sizes of these user populations have been estimated based on published estimates of the number of individuals with each of several diseases who (1) also need a wheeled mobility device and (2) have specific symptoms that could interfere with mobility device use. PMID: 18566926 [PubMed - indexed for MEDLINE] Free full text

Arch Phys Med Rehabil. 2013 Apr;94(4 Suppl):S137-44. doi: 10.1016/j.apmr.2012.10.035.

Pain and its impact on inpatient rehabilitation for acute traumatic spinal cord injury: analysis of observational data collected in the SCIRehab study. Zanca JM, Dijkers MP, Hammond FM, Horn SD. Source Department of Rehabilitation Medicine, Mount Sinai School of Medicine, New York, NY, USA. [email protected] Abstract OBJECTIVE: To describe pain during inpatient rehabilitation and its impact on delivery of inpatient rehabilitation services for persons with spinal cord injury (SCI). DESIGN: Prospective observational study and retrospective chart review. SETTING: Six inpatient rehabilitation facilities participating in the SCIRehab Study. PARTICIPANTS: Patients (N=1357) receiving initial rehabilitation after traumatic SCI, for whom pain data were available. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Self-reported rating of pain intensity (0-10), pain locations, and treatment time by various rehabilitation disciplines. RESULTS: The vast majority of patients (97%) reported pain at least once during the rehabilitation stay, with an average pain intensity SD of 4.9 2.4. Average pain intensity over the stay was severe (rated 7-10) for 30% of patients, moderate (4-6) for 42%, and mild (1-3) for 25%. Pain prevalence at admission was greater than at discharge (87% vs 74%), as was pain intensity (6.0 vs 4.6). Most (79%) of the 177 participants who did not have pain at admission reported pain at least once later in the rehabilitation stay, but their average high pain intensity over the stay was lower than that of the full sample (1.9 vs 4.9). Nearly half (47%) of patients reported pain at 3 locations during the stay, with the back, neck, and shoulder commonly reported. Patients with severe pain spent fewer days in rehabilitation, received less rehabilitation treatment time (hours per week and total hours), and had more treatment sessions altered in objective or content because of pain than those with lower pain levels.

CONCLUSIONS: Pain is a common problem for persons receiving inpatient rehabilitation for traumatic SCI and adversely impacts delivery of therapy services. Copyright 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved. PMID: 23527769 [PubMed - indexed for MEDLINE]

Disabil Rehabil. 2013 Jun;35(13):1119-26. doi: 10.3109/09638288.2012.709301. Epub 2012 Aug 20.

Design of a randomized-controlled trial on low-intensity aerobic wheelchair exercise for inactive persons with chronic spinal cord injury.
van der Scheer JW, de Groot S, Postema K, Veeger DH, van der Woude LH.

Source
University of Groningen, University Medical Center Groningen, Center for Human Movement Sciences , the Netherlands.

Abstract
Purpose: To investigate effects and working mechanisms of low-intensity aerobic wheelchair exercise on fitness, (upper-body) health and active lifestyle in inactive persons with chronic spinal cord injury (SCI). Methods: A multicenter randomized-controlled trial (RCT) in 40 inactive manual wheelchair users (aged 28-65y) with chronic paraplegia or tetraplegia (time since injury >10y). Subjects will be randomly assigned to an intervention or a control group. The intervention will consist of 16 weeks (2 times per week, 30min per session) of low-intensity aerobic handrim wheelchair exercise (30-40% HRR) on a treadmill. Repeated measurements will be performed before starting the intervention or entrance of the control group, and after week 8, 16 and 42 following the start. The primary outcome will be wheelchair-specific physical fitness. Secondary outcomes will be upper-body pain and discomfort, shoulder load, propulsion technique, wheelchair skill performance and physical activity levels. Conclusions: Results of this first RCT on low-intensity aerobic wheelchair exercise for inactive persons with chronic SCI can improve SCI-specific exercise guidelines and provide an evidence-base for an aftercare program aimed at preserving fitness, health and active lifestyle of persons aging with SCI. [Box: see text]. PMID: 22900530 [PubMed - in process]

Arch Phys Med Rehabil. 2012 Aug;93(8):1421-30. doi: 10.1016/j.apmr.2012.02.034. Epub 2012 Apr 3.

Effect of shoulder pain on shoulder kinematics during weightbearing tasks in persons with spinal cord injury.
Nawoczenski DA, Riek LM, Greco L, Staiti K, Ludewig PM.

Source
Dept of Physical Therapy, Ithaca CollegeRochester Center, 1100 S Goodman St, Rochester, NY 14620, USA. [email protected]

Abstract
OBJECTIVE: To assess 3-dimensional scapulothoracic and glenohumeral kinematics between subjects with spinal cord injury and disease (SCI/D) with and without shoulder pain during a weight-relief raise and transfer task. DESIGN: Case-control, repeated-measures analysis of variance. SETTING: Movement analysis laboratory. PARTICIPANTS: Subjects (N=43; 23 with clinical signs of impingement and 20 without) between 21 and 65 years of age, at least 1 year after SCI/D (range, 1-43y) resulting in American Spinal Injury Association Impairment Scale T2 motor neurologic level or below, and requiring the full-time use of a manual wheelchair. INTERVENTIONS: Weight-relief raises and transfer tasks. MAIN OUTCOME MEASURES: An electromagnetic tracking system acquired 3-dimensional position and orientation of the thorax, scapula, and humerus. Dependent variables included angular values for scapular upward and downward rotation, posterior and anterior tilt, and internal and external rotation relative to the thorax, and glenohumeral internal and external rotation relative to the scapula. The mean of 3 trials was collected, and angular values were compared at 3 distinct phases of the weight-relief raise and transfer activity. Comparisons were also made between transfer direction (lead vs trail arm) and across groups. RESULTS: Key findings include significantly increased scapular upward rotation for the pain group during transfer (P=.03). Significant group differences were found for the trailing arm at the lift pivot (phase 2) of the

transfer, with the pain group having greater anterior tilt (mean difference SE, 5.72.8). The direction of transfer also influenced kinematics at the different phases of the activity. CONCLUSIONS: Potentially detrimental magnitude and direction of scapular and glenohumeral kinematics during weight-bearing tasks may pose increased risk for shoulder pain or injury in persons with SCI/D. Consideration should be given to rehabilitation strategies that promote favorable scapular kinematics and glenohumeral external rotation. Copyright 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved. PMID: 22481126 [PubMed - indexed for MEDLINE]

Phys Ther. 2000 Mar;80(3):276-91.

Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement.
Ludewig PM, Cook TM.

Source
Program in Physical Therapy, Department of Physical Medicine and Rehabilitation, Box 388 Mayo, 420 Delaware St, University of Minnesota, Minneapolis, MN 55455, USA. [email protected].

Abstract
BACKGROUND AND PURPOSE: Treatment of patients with impingement symptoms commonly includes exercises intended to restore "normal" movement patterns. Evidence that indicates the existence of abnormal patterns in people with shoulder pain is limited. The purpose of this investigation was to analyze glenohumeral and scapulothoracic kinematics and associated scapulothoracic muscle activity in a group of subjects with symptoms of shoulder impingement relative to a group of subjects without symptoms of shoulder impingement matched for occupational exposure to overhead work. SUBJECTS: Fifty-two subjects were recruited from a population of construction workers with routine exposure to overhead work. METHODS: Surface electromyographic data were collected from the upper and lower parts of the trapezius muscle and from the serratus anterior muscle. Electromagnetic sensors simultaneously tracked 3dimensional motion of the trunk, scapula, and humerus during humeral elevation in the scapular plane in 3 handheld load conditions: (1) no load, (2) 2. 3-kg load, and (3) 4.6-kg load. An analysis of variance model was used to test for group and load effects for 3 phases of motion (31(-60(, 61(-90(, and 91(-120(). RESULTS: Relative to the group without impingement, the group with impingement showed decreased scapular upward rotation at the end of the first of the 3 phases of interest, increased anterior tipping at the end of the third phase of interest, and increased scapular medial rotation under the load conditions. At the same time, upper and lower trapezius muscle electromyographic activity increased in the group with impingement as compared with the group without impingement in the final 2 phases, although the upper trapezius muscle changes were apparent only during the 4.6-kg load condition. The serratus anterior muscle demonstrated decreased activity in the group with impingement across all loads and phases. CONCLUSION AND DISCUSSION: Scapular tipping (rotation about a medial to lateral axis) and serratus anterior muscle function are important to consider in the rehabilitation of patients with symptoms of shoulder impingement related to occupational exposure to overhead work. [Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement.

PMID: 10696154 [PubMed - indexed for MEDLINE] Free full text

Spinal Cord. 2012 Jun;50(6):457-61. doi: 10.1038/sc.2011.160. Epub 2012 Jan 31.

Effects of an exercise programme on musculoskeletal and neuropathic pain after spinal cord injury--results from a seated double-poling ergometer study.
Norrbrink C, Lindberg T, Wahman K, Bjerkefors A.

Source
Department of Clinical Sciences, Karolinska Institutet Danderyd Hospital, Stockholm, Sweden.

Abstract
OBJECTIVES: To assess pain relieving effects of an intensive exercise programme on a seated double-poling ergometer in individuals with spinal cord injury (SCI). SETTING: Stockholm, Sweden. METHODS: A total of 13 wheelchair-dependent individuals with a thoracic or lumbar SCI were recruited to a 10week training period (three times weekly) assessing the effects of regular training on upper-body strength, aerobic and mechanical power, and crossover effects on functional performance, as well as cardiovascular risk factors. Eight of the participants reported pain and were included in this exploratory pain protocol and assessed using the International SCI Basic Pain Data set, the Wheelchair Users' Shoulder Pain Index and International SCI Quality of Life Basic Data set. RESULTS: For those with neuropathic pain, median pain intensity ratings decreased from 5 on a 0-10 numerical rating scale at base-line to 3 at the end of study, and four of seven participants reported an improvement on the Patient Global Impression of Change scale. For those with musculoskeletal pain (n = 5), median pain intensity ratings improved from 4 at baseline to 0 at the end of study. All but one rated no musculoskeletal pain at all at the end of study and number of days with pain per week decreased from 5.5 to 0.7. None of the participants developed pain, because of overuse during the training period and few reported unwanted side effects. CONCLUSION: Considering its promising effects and safety, an intensive exercise programme can be tried for treating musculoskeletal pain and also neuropathic pain following SCI. PMID: 22289901 [PubMed - indexed for MEDLINE]

Spinal Cord. 2011 Jun;49(6):761-3. doi: 10.1038/sc.2010.89. Epub 2010 Aug 24.

Suprascapular nerve entrapment in a patient with a spinal cord injury.

Facione J, Beis JM, Kpadonou GT, Lagauche D, Touillet A, Braun M, Le Chapelain L, Paysant J.

Source
Institut Rgional de Mdecine Physique et de Radaptation, Nancy, France.

Abstract
STUDY DESIGN: Case report. OBJECTIVES: To describe a case of suprascapular nerve entrapment (SNE) in a patient with a spinal cord injury (SCI) as a cause of shoulder pain. SETTING: Physical Medicine and Rehabilitation Institute, Nancy, France. REPORT: Six months after the occurrence of acute paraplegia T9 ASIA, a 45-year-old man complained of pain in the posterior and lateral areas of the left shoulder. A clinical assessment found an atrophy of the infraspinatus muscle and a muscular weakness during external shoulder rotation. SNE was suggested as a cause of pain and confirmed by nerve conduction recording. Magnetic resonance imaging excluded any compressive cyst. SNE at the spinoglenoid notch, related to upper limb overuse, was suggested. A gluco-corticoid injection in the proximity of the suprascapular nerve eliminated the pain in a few hours. Two months after the injection, the pain had not reappeared, the infraspinatus muscle atrophy was resolved, and supraspinal nerve conduction was normalized. CONCLUSION: Shoulder pain is common in individuals with paraplegia, but this is the first time that SNE has been reported as a cause of pain. This micro-traumatic pathology, well known in athletes, is probably under-diagnosed in patients with SCI who overuse their upper limbs for wheelchair propulsion and body transfers. PMID: 20733590 [PubMed - indexed for MEDLINE]

http://www.rehab.research.va.gov/jour/05/42/5/cruz-almeida.html 21 June 2013 **Penting**

Yahoo.pic

http://www.healio.com/orthopedics/journals/ORTHO/%7B8ECB36E9-6B4E4259-A448-DED59096209D%7D/Patient-Outcomes-Following-AnteriorCruciate-Ligament-Reconstruction-The-Influence-of-Psychological-Factors 21 June 2013-06-21

The Janda Approach

GRIP Approach is pleased to present The Janda Approach To Musculoskeletal Pain Syndromes as taught by his long time pupil Robert Lardner, PT

Protective reflexes serve as the basis for all human movement and dominate in Pathology Janda

Vladimir Janda Md, DSC is considered to be the father of Czech rehabilitation and one of a handful of physicians responsible for how the rehabilitation field was shaped internationally. He systematically defined characteristic and predictable muscle imbalance syndromes in relationship to the adaptations of the CNS and the ensuing chronicity something we commonly call Jandas crossed syndromes. He viewed the sensory motor system as an indivisible unit and stressed that effective treatment and the rehabilitation process would have to respect this unity and its implications. His teachings influenced many people, including Robert Lardner who co-authored the book Assessment and Treatment of Muscle Imbalance The Janda Approach.

Injury statistics for musculoskeletal disorders (all industries)

Rate this page The image below shows the most common musculoskeletal injuries experienced by workers. Click on the circles to access more information about the injury statistics and practical solutions for making your workplace healthier and safer.

Source: Queensland Employee Injury Database. Data current as at August 2008 and is subject to change over time. Based on accepted workers' compensation claims, excluding commuting claims, between 2000-01 and 2006-07 which resulted in a musculoskeletal injury.

J Spinal Cord Med. 2005;28(5):407-14.

Biomechanics and strength of manual wheelchair users.

Ambrosio F, Boninger ML, Souza AL, Fitzgerald SG, Koontz AM, Cooper RA.

Source
Department of Rehabilitation Science and Technology, University of Pittsburgh, Pennsylvania, USA.

Abstract
BACKGROUND/OBJECTIVE: Previous investigations have identified muscular imbalance in the shoulder as a source of pain and injury in manual wheelchair users. Our aim was to determine whether a correlation exists between strength and pushrim biomechanical variables including: tangential (motive) force (Ft), radial force (Fr), axial force (Fz), total (resultant) force (FR), fraction of effective force (FEF), and cadence. METHODS: Peak isokinetic shoulder strength (flexion [FLX], extension [EXT], abduction [ABD], adduction [ADD], internal rotation [IR], and external rotation [ER]) was tested in 22 manual wheelchair users with a BioDex system for 5 repetitions at 60 degrees/s. Subjects then propelled their own manual wheelchair at 2 speeds, 0.9 m/s (2 mph) and 1.8 m/s (4 mph), for 20 seconds, during which kinematic (OPTOTRAK) and kinetic (SMARTWHEEL) data were collected. Peak isokinetic forces in the cardinal planes were correlated with pushrim biomechanical variables. RESULTS: All peak torque strength variables correlated significantly (P < or = 0.05) with Ft, Fr, and FR, but were not significantly correlated with Fz, FEF, or cadence. Finally, there were no relationships found between muscle strength ratios (for example, FLX/EXT) and Ft, Fr, FR, Fz, or FEF. CONCLUSION: There was a correlation between strength and force imparted to the pushrim among wheelchair users; however, there was no correlation found in wheelchair propulsion or muscle imbalance. Clinicians should be aware of this, and approach strength training and training in wheelchair propulsion techniques separately. PMID: 16869087 [PubMed - indexed for MEDLINE] PMCID: PMC1808266

J Spinal Cord Med. 2005;28(3):222-9.

Effect of fore-aft seat position on shoulder demands during wheelchair propulsion: part 2. An electromyographic analysis.
Gutierrez DD, Mulroy SJ, Newsam CJ, Gronley JK, Perry J.

Source
Pathokinesiology Laboratory, Rancho Los Amigos National Rehabilitation Center, 7601 E. Imperial Highway, Building 800, Room 33, Downey, CA, 90242, USA. [email protected]

Abstract
BACKGROUND/OBJECTIVES: Shoulder pain is common in persons with complete spinal cord injury. Adjustment of the wheelchairuser interface has been thought to reduce shoulder demands. The purpose of this study was to quantify the effect of seat fore-aft position on shoulder muscle activity during wheelchair propulsion. METHODS: Shoulder electromyography (EMG) was recorded while 13 men with paraplegia propelled a wheelchair in the following 2 seat positions: (a) shoulder joint center aligned with the wheel axle (anterior) and (b) shoulder joint center 8 cm posterior to the wheel axle (posterior) in 3 test conditions (free, fast, and graded). Duration of EMG activity and median and peak intensities were compared. RESULTS: During free propulsion, the median EMG intensity of all muscles was similar between anterior and posterior seat positions. The major propulsive muscles (pectoralis major and anterior deltoid) demonstrated significant reductions in their median and peak intensities in the posterior seat position. Pectoralis major median intensity was significantly reduced in the posterior position during fast (52% vs 66% maximal muscle test [MMT]) and graded (41 % vs 49% MMT) conditions, and peak intensity was significantly reduced in the free condition (29% vs 52% MMT) and the fast condition (103% vs 150% MMT). Anterior deltoid intensity was significantly reduced in the posterior position during fast propulsion only (26% vs 31% MMT). For all muscles, EMG duration was similar between positions in all test conditions. CONCLUSIONS: Reduction in the intensity of the primary push phase muscles (pectoralis major and anterior deltoid) during high-demand activities of fast and graded propulsion may reduce the potential for shoulder muscle fatigue and injuries. PMID: 16048140 [PubMed - indexed for MEDLINE]

J Spinal Cord Med. 2005;28(3):214-21.

Effect of fore-aft seat position on shoulder demands during wheelchair propulsion: part 1. A kinetic analysis.
Mulroy SJ, Newsam CJ, Gutierrez DD, Requejo P, Gronley JK, Haubert LL, Perry J.

Source
Pathokinesiology Laboratory, Rancho Los Amigos National Rehabilitation Center, 7601 E. Imperial Highway, Building 800, Room 33, Downey, CA, 90242, USA.

Abstract
BACKGROUND/OBJECTIVE: The highly repetitive and weight-bearing nature of wheelchair (WC) propulsion has been associated with shoulder pain among persons with spinal cord injury (SCI). Manipulation of WC seat position is believed to reduce the overall demand of WC propulsion. The objective of this investigation was to document the effect of fore-aft seat position on shoulder joint kinetics. METHODS: Thirteen men with complete motor paraplegia propelled a test WC in 2 fore-aft seat positions during free, fast, and graded conditions. The seat-anterior position aligned the glenohumeral joint with the wheel axle and the seat-posterior position moved the glenohumeral joint 8 cm posteriorly. The right wheel of the test chair was instrumented to measure forces applied to the pushrim. An inverse dynamics algorithm was applied to calculate shoulder joint forces, external moments, and powers. RESULTS: For all test conditions, the superior component of the shoulder joint resultant force was significantly lower in the seat-posterior position. During graded propulsion, the posterior component of the shoulder joint force was significantly higher with the seat posterior. Peak shoulder joint moments and power were similar during free and fast propulsion. During graded propulsion, the seat-posterior position displayed increased internal rotation moment, decreased sagittal plane power absorption, and increased transverse plane power generation. CONCLUSIONS: This investigation provides objective support that a posterior seat position reduces the superior component of the shoulder joint resultant force. Consequently, this intervention potentially diminishes the risk for impingement of subacromial structures. PMID: 16048139 [PubMed - indexed for MEDLINE]

Arch Phys Med Rehabil. 2004 Jul;85(7):1151-9.

A new method to quantify demand on the upper extremity during manual wheelchair propulsion.
Sabick MB, Kotajarvi BR, An KN.

Source
Orthopedic Biomechanics Laboratory, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. [email protected]

Abstract
OBJECTIVE: To use an ergonomics-based rating that characterizes both demand on, and capacity of, upperextremity muscle groups during wheelchair propulsion to help identify the muscle groups most at risk for pain or overuse injury in a relatively demanding wheelchair propulsion task. DESIGN: Case series. SETTING: Biomechanics research laboratory. PARTICIPANTS: Sixteen manual wheelchair users with complete (American Spinal Injury Association grade A) T6-L2 paraplegia. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Internal peak joint moments required by each of the major upper-extremity muscle groups for propelling a wheelchair up a ramp; isometric strength of each of the muscle groups in positions simulating wheelchair propulsion; and wheelchair propulsion strength rating (WPSR) for each muscle group, calculated by normalizing the joint demands to their capacity. RESULTS: The largest joint moment was for shoulder flexion, at 39.7+/-13.9Nm. Shoulder flexion also accounted for the peak WPSR value of 66.5%+/-20.3%. Supination and pronation movements had low peak moment requirements (3.4Nm, 5.0Nm, respectively) but high WPSR values (41%, 53%, respectively). CONCLUSIONS:

Even a relatively benign ramp (2.9 degrees ) places a large demand on the musculature of the upper extremity, as assessed by using the WPSR to indicate muscular demand. PMID: 15241767 [PubMed - indexed for MEDLINE]

J Shoulder Elbow Surg. 2011 Oct;20(7):1108-13. doi: 10.1016/j.jse.2011.03.021. Epub 2011 Jul 2.

A cross-sectional study of demographic and morphologic features of rotator cuff disease in paraplegic patients.
Akbar M, Brunner M, Balean G, Grieser T, Bruckner T, Loew M, Raiss P.

Source
Orthopaedic Department, University of Heidelberg, Heidelberg, Germany.

Abstract
BACKGROUND: This study analyzed the demographic and morphologic features of rotator cuff disease in paraplegic patients who presented with or without shoulder pain. METHODS: Clinical and magnetic resonance imaging examinations of both shoulders were performed in 317 paraplegic patients. Mean age was 49 (range, 19-76) years. The level of spinal cord injury was between T2 and T7 In 54% of patients and between T8 and L3 in 46%. Constant scores were measured for all shoulders. Pain was analyzed using a visual analog scale. RESULTS: Rotator cuff tears were not present in 51%, were unilateral in 20%, and were bilateral in 29%. Age was older and duration of spinal cord injury was significantly longer in patients with bilateral tears than in patients without or with unilateral tears (P < .001). In patients with unilateral tears, a full-thickness rupture of the supraspinatus tendon was found in 67%, whereas a partial-rupture was detected in 33%. Of the patients with bilateral tears, 75% presented with a full-thickness rupture and 25% with a partial rupture. The mean Constant score was 76 (range, 37-98) in patients without cuff tears, 69 (range, 16-94) for patients with unilateral tears, and 64 (16-96) for patients with bilateral tears (P < . 001). CONCLUSIONS: Rotator cuff disease is common and correlates highly with age and duration of spinal cord injury, which underlines the theory of "wear and tear" in wheelchair-dependent patients. Copyright 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved. PMID: 21724421 [PubMed - indexed for MEDLINE]

J Bone Joint Surg Am. 2009 Aug;91(8):1898-906. doi: 10.2106/JBJS.G.01335.

Outcome of nonoperative treatment of symptomatic rotator cuff tears monitored by magnetic resonance imaging.
Maman E, Harris C, White L, Tomlinson G, Shashank M, Boynton E.

Source
Department of Orthopedics B, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, TelAviv University, 6 Weizman Street, Tel-Aviv 64239, Israel. [email protected]

Abstract
BACKGROUND: Rotator cuff tears are very common, but little is known about the outcome of nonoperative treatment of symptomatic tears in terms of progression and the need for surgical intervention. METHODS: Fifty-nine shoulders in fifty-four patients (thirty-three women and a mean age of 58.8 years) with rotator cuff tears on initial magnetic resonance imaging who had been managed nonoperatively were studied retrospectively. All had magnetic resonance imaging scans acquired six months or more after the initial study. The progression of the rotator cuff tears was associated with age, anatomical and associated parameters, follow-up time, and structural and other magnetic resonance imaging findings. RESULTS: Baseline magnetic resonance imaging scans demonstrated thirty-three full-thickness tears, twenty-six partial-thickness tears, and four combined full-thickness and partial-thickness tears. Fifty-eight of the fifty-nine tears involved the supraspinatus tendon, and ten involved multiple tendons. Progression in tear size occurred more often among the patients who were followed more than eighteen months (thirteen [48%] of twenty-seven shoulders) compared with those who were followed for less than eighteen months (six [19%] of thirty-two shoulders). Five tears (one partial-thickness tear) decreased in size. More than half (52%; seventeen) of the thirty-three full-thickness tears increased in size compared with 8% (two) of the twenty-six partial-thickness tears (p = 0.0005). Only 17% (six) of the thirty-five tears in patients who were sixty years old or less deteriorated compared with 54% (thirteen) of the twenty-four tears in patients who were more than sixty years old (p = 0.007). No shoulder in a patient with a partial-thickness tear demonstrated supraspinatus atrophy, whereas 24% of those with a full-thickness tear demonstrated atrophy (p = 0.007). The proportion with an increase in tear size was significantly larger for shoulders with fatty infiltration than for those without it (p = 0.0089). CONCLUSIONS: Factors that are associated with progression of a rotator cuff tear are an age of more than sixty years, a full-thickness tear, and fatty infiltration of the rotator cuff muscle(s). In the long-term follow-up of nonoperatively treated rotator cuff tears, magnetic resonance imaging can be used to monitor rotator cuff changes and guide patient management. PMID: 19651947 [PubMed - indexed for MEDLINE]

J Spinal Cord Med. 1995 Jan;18(1):9-13.

Prevalence and impact of wrist and shoulder pain in patients with spinal cord injury.
Subbarao JV, Klopfstein J, Turpin R.

Source
Hines Comprehensive Rehabilitative Services, Edward Hines Jr. Veterans Affairs Hospital, IL 60141, USA.

Abstract
Spinal cord injury (SCI) patients experience varying degrees of wrist and shoulder pain. Previous studies indicated that 30 to 64 percent of SCI patients reported chronic shoulder pain. The purpose of this study was to identify the prevalence of chronic wrist and shoulder pain, to determine which activities caused or exacerbated the pain, and assess functional and emotional responses to chronic pain and identify ways in which the pain might be reduced. Eight hundred SCI patients were surveyed by questionnaire with 451 (66 percent) responding. In addition, 30 patients were available for clinical observation and evaluation. Data was evaluated using the Statistical Analysis System and the Cornell Personal Adjustment Scale. Results indicated that wrist and shoulder pain were more prevalent than previously indicated (72.7 percent of respondents reported some degree of chronic pain in one or both of these areas), wheelchair propulsion and transfers caused most pain and also increased the degree of pain. Patient's age, neurologic level and time since injury were not statistically significant in the study and emotional responses did not significantly vary between groups with and without pain. Further, it was noted that among the pain group, various routine therapies were not effective. We conclude that alternative methods for wheelchair propulsion and transfers, which lessen stress and cumulative trauma, need to be developed for SCI patients in order to diminish the incidence of chronic upper limb pain. PMID: 7640974 [PubMed - indexed for MEDLINE]

Paraplegia. 1994 Apr;32(4):211-8.

Upper limb function in persons with long term paraplegia and implications for independence: Part I.
Pentland WE, Twomey LT.

Source
School of Rehabilitation Therapy, Queen's University, Kingston, Canada.

Abstract
The intent of this study was to describe the effects of long term paraplegia and wheelchair use on upper limb function. Bilateral upper extremity isokinetic and grip strength, pain, and active range of motion were compared in 52 men with paraplegia (mean age 44 years; mean duration of spinal cord injury (SCI) 17 years) and 52 age and activity level matched able bodied men. The impact of upper limb pain on activities of daily living (ADL) performance was examined in the paraplegic sample. Strength was not significantly different between the two samples except for bilateral shoulder flexion (able bodied stronger) and bilateral elbow extension (paraplegia stronger). Strength changed similarly with age in the two groups. The effect of duration of SCI on strength, excluding age, was significant for grip strength only. Duration of paraplegia and activity level were better predictors of strength than age in 9 of 14 muscle groups tested, whereas in the able bodied, age was the best strength predictor. Limited bilateral shoulder internal rotation and nondominant external rotation were associated with paraplegia (shoulder p < 0.001; elbow p < 0.001; wrist/hand p < 0.001). Reported pain prevalences for the paraplegic sample were: shoulder 39%; elbow 31% and wrist/hand 40%. The paraplegic subjects' pain intensity ratings revealed them to be experiencing mild to moderate levels of upper limb pain. Shoulder pain was associated with duration of injury, exclusive of age (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Clin Orthop Relat Res. 1988 Aug;(233):132-5.

Late complications of the weight-bearing upper extremity in the paraplegic patient.

Gellman H, Sie I, Waters RL.

Source
University of Southern California Department of Orthopaedic Surgery, Rancho Los Amigos Hospital.

Abstract
Paraplegic patients rely almost exclusively on their upper extremities for weight-bearing activities such as transfers and wheelchair propulsion. Eighty-four paraplegic patients whose injury level was T2 or below and who were at least one year from spinal cord injury were screened for upper extremity complaints. Fifty-seven (67.8%) had complaints of pain in one or more areas of their upper extremities. The most common complaints were shoulder pain and/or pain relating to carpal tunnel syndrome. Twenty-five (30%) complained of shoulder pain during transfer activities. Symptoms were found to increase with time from injury. As the long-term survival of spinal cord injured patients continues to improve, an increased awareness of the complications of the weight-bearing upper extremity is necessary to keep these patients functioning in society. PMID: 3402118 [PubMed - indexed for MEDLINE]

Clin Orthop Relat Res. 2002 Oct;(403 Suppl):S26-36.

Shoulder biomechanics and muscle plasticity: implications in spinal cord injury.

Lee TQ, McMahon PJ.

Source
Orthopaedic Biomechanics Laboratory, VA Healthcare System, Long Beach, CA, USA.

Abstract
After spinal cord injury, excessive burden falls on the upper extremity, especially the shoulder. Overall, 51% of persons with spinal cord injury have shoulder problems. Common shoulder problems in persons with spinal cord injury begin with muscle imbalance that can lead to glenohumeral instability, impingement disease, rotator cuff tears, and subsequent degenerative joint disease. These problems can be attributed to the functional demands placed on the shoulder that are specific to patients with spinal cord injury, including overhead activities, wheelchair use, and transfers. Despite preventive exercises, shoulder problems in persons with spinal cord injury remain a significant problem, causing pain and functional limitations. The biomechanics of the shoulder for persons with spinal cord injury resulting from changes in muscle plasticity will be elucidated. Specifically, the effects of scapular protraction that can result from muscle imbalance, the age-dependent properties of the anterior band of the inferior glenohumeral ligament, and the influence of the dynamic restraints around the shoulder will be addressed. PMID: 12394450 [PubMed - indexed for MEDLINE]

SCI Nurs. 1996 Jun;13(2):39-44.

Patient evaluation of prone carts used in spinal cord injury.

Nelson A, Malassign P, Cors M, Amerson TL, Bonifay R, Schnurr E.

Abstract
Prone carts are used for mobility by individuals with spinal cord injury who cannot use a wheelchair due to the risk of aggravating existing pressure ulcers. A prone cart is a flat/horizontal cart with a fixed height, propelled by the user while laying in a prone position. Patients reported that prolonged use of a prone cart resulted in chronic neck, shoulder and back pain. Additionally the existing prone carts lack user accessible angle adjustability, chest support area, as well as a storage, eating or working area. An interdisciplinary research team collaborated to address these concerns. Three prone carts were evaluated: E&J, Gendron, and a newly developed prototype, MIAD/PVA. Questionnaires were administered to caregivers and patients regarding usage and effectiveness of the prone carts as well as the features of an ideal cart. This data led to the design and refinement of a prototype prone cart which was tested on 20 patients and 19 caregivers at the SCI Centers of the Milwaukee and Tampa VAMC's from 1994-1995. The new prone cart enables the user to lie at an angle rather than laying flat. This position has been found to relieve back and neck pressure. With an hydraulic system, the the user can adjust both the front and rear angles of the cart to achieve desired comfort. In addition, a front deck provides an eating and working area. This study resulted in research-based information and criteria for the design of new prone carts. Findings of this pilot study will be incorporated in a development merit review proposal to the VA Rehabilitation Research & Development service for the design of a new manual and motorized prone cart. The researchers are collaborating with OrthoKinetics Inc. to promote ease in manufacturing. PMID: 8900708 [PubMed - indexed for MEDLINE]

Spinal Cord. 2000 Nov;38(11):649-57.

Preserving transfer independence among individuals with spinal cord injury.

Nyland J, Quigley P, Huang C, Lloyd J, Harrow J, Nelson A.

Source
School of Physical Therapy, University of South Florida, Tampa 33612-4766, USA.

Abstract
STUDY DESIGN: Literature review. OBJECTIVES: Upper extremity (UE) joint degeneration, particularly at the shoulder, detrimentally influences functional independence, quality of life, cardiovascular disease risk, and life expectancy of individuals following spinal cord injury (SCI). This review (1) describes UE use for transfers among individuals with SCI; (2) describes contributing factors associated with UE joint degeneration and loss of transfer independence; (3) summarizes and identifies gaps in existing research; and (4) provides suggestions for future research. RESULTS: Investigations of wheelchair transfer related UE joint and function preservation among individuals with SCI should consider factors including age and length of time from SCI onset, interface between subject-wheelchair, pain, shoulder joint range of motion (ROM) and muscle strength deficiencies or imbalances, exercise capacity and tolerance for the physical strain of activities of daily living (ADL), body mass and composition, previous UE injury or disease history, and transfer techniques. Existing studies of transfers among individuals with SCI have relied on small groups of either asymptomatic or non-impaired subjects, with minimal integration of kinematic, kinetic and electromyographic data. Descriptions of UE joint ROM, forces, and moments produced during transfers are lacking. CONCLUSIONS: Biomechanical measurement and computer modeling have provided increasingly accurate tools for acquiring the data needed to guide intervention planning to prevent UE joint degeneration and preserve function among individuals with SCI. The identification of stressful sub-components during transfers will enable intervening clinicians and engineers who design and modify assistive and adaptive devices to better serve individuals with SCI.
PMID: 11114770 [PubMed - indexed for MEDLINE

Arch Phys Med Rehabil. 1990 Nov;71(12):1006-9.

A new orthosis for central cord syndrome and brachial plexus injuries.
Kohlmeyer KM, Weber CG, Yarkony GM.

Source
Rehabilitation Institute of Chicago, IL 60611.

Abstract
Proximal upper extremity weakness may develop secondary to central cord syndrome due to spinal cord injury or brachial plexus injury. Functional deficits, pain, decreased upper extremity arm swing during gait, and shoulder subluxation are common sequelae of these injuries. This report describes a new orthotic design that can be easily fabricated in two to four hours from readily available materials to compensate for these deficits. This orthosis allows for early participation in activities of daily living for patients with greater proximal than distal upper extremity weakness. The orthosis consists of a figure-eight shoulder harness and unilateral or bilateral forearm cuffs of orthoplast connected to the harness by flexible rubber tubing. The length of the tubing is adjustable through clamps connected to the forearm cuff to allow for variable arm positioning. Three patients, aged 14, 64, and 68, two with central cord syndrome and one with injury to the upper portion of the brachial plexus (Erb palsy) are described. Shoulder girdle musculature was less than 2, biceps less than 2, triceps less than 4, and hands less than 5 in all patients. Benefits from use of this orthosis may include improved arm swing and balance during ambulation, reduced shoulder pain and subluxation, and increased independence for tasks such as carrying lightweight objects, lower extremity dressing, bathing, light homemaking, and leisure activities such as gardening. PMID: 2241538 [PubMed - indexed for MEDLINE]

Google scholar 2013-06-25

Next MedicalEngineering& Physics Volume 35, Issue 8 , Pages 1141-1149, August 2013

Reconfiguration of the upper extremity relative to the pushrim affects load distribution during wheelchair propulsion

Joseph M. Munaretto Jill L. McNitt-Gray , Henryk Flashner , Philip S. Requejo

Received 18 November 2011; received in revised form 18 November 2012; accepted 6 December 2012. published online 25 January 2013

Abstract
Objective
Repetitive loading during manual wheelchair propulsion (WCP) is associated with overuse injury to the upper extremity (UE). The aim of this study was to determine how RF redirection and load distribution are affected by changes upper extremity kinematic modifications associated with modifications in seat positions during a WCP task. The aim of this study was to determine how RF redirection and load distribution are affected by upper extremity kinematic changes associated with seat position adjustment during a WCP task.

Design
Dynamic simulations using an experiment-based multi-link inverse dynamics model were used to generate solutions for redistributing UE mechanical load in different seating positions without decrements in WCP task performance.

Methods
Experimental RF and kinematic data were collected for one subject propelling at a self-selected speed and used as input into the model. Shoulder/axle distance, wrist angular position, and RF direction were systematically modified to simulate how the mechanical demand imposed on the upper extremity (elbow and shoulder net joint moments (NJMs) and net joint forces) may vary.

Results
Load distribution depended on UE orientation relative to the wheel. At peak force, lower shoulder/axle distances and more anterior wrist positions on the pushrim allowed for more extended elbow positions and reduced total NJM load.

Interpretation
Simulation results incorporating subject-specific data may provide mechanically based information to guide clinical interventions that aim to maintain WCP performance and redistribute load by modifying RF direction, seat configuration and hand/rim interaction.

****Variability of peak shoulder force during wheelchair propulsion as a function of shoulder pain
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Title: Variability of peak shoulder force during wheelchair propulsion as a function of shoulder pain Author(s): Moon, Yaejin Advisor(s): Sosnoff, Jacob J. Department / Kinesiology & Community Health Program: Graduate Major: Kinesiology Degree Granting University of Illinois at Urbana-Champaign Institution: Degree: M.S. Genre: Thesis Subject(s): variability motor variability wheelchair wheelchair propulsion shoulder pain shoulder injury Abstract: Manual wheelchair users report a high prevalence of shoulder pain. Growing evidence shows that variability in forces applied to biological

tissue is related to musculoskeletal pain. The purpose of this study was to examine the variability of forces acting on the shoulder during wheelchair propulsion as a function of shoulder pain. Twenty-nine manual wheelchair users (13 with pain, 16 without pain) participated in the investigation. Kinetic and kinematic data of wheelchair propulsion were recorded for three minutes maintaining a constant speed at three distinct propulsion speeds (fast speed of 1.1m/s, a self-selected speed, and a slow speed of 0.7m/s). Peak resultant shoulder forces in push phase were calculated using inverse dynamics. There was no difference in mean shoulder resultant force between groups. The pain group had significantly smaller variability of peak resultant force than the no pain group (p < 0.01). This highlights that manipulations of propulsion variability could potentially be a novel prevention strategy for upper limb pain in manual wheelchair users. Issue Date: 2013-05-24 URI: http://hdl.handle.net/2142/44139 Rights Information: Copyright 2013 Yaejin Moon Date Available in 2013-05-24 IDEALS: Date Deposited: 2013-05

*****Br J Sports Med doi:10.1136/bjsports-2013-092425

Original article

Clinical implications of scapular dyskinesis in shoulder injury: the 2013 consensus statement from the scapular summit 1. 2. 3. 4. 5. 6. W Ben Kibler1, Paula M Ludewig2, Phil W McClure3, Lori A Michener4, Klaus Bak5, Aaron D Sciascia1

+ Author Affiliations 1. 2. 3. 4. 5.
1

Shoulder Center of Kentucky, Lexington, Kentucky, USA Department of Physical Therapy, University of Minnesota, Minneapolis, Minnesota, USA Department of Physical Therapy, Arcadia University, Philadelphia, Pennsylvania, USA Department of Physical Therapy, Virginia Commonwealth University, Richmond, Virginia, USA Department of Shoulder Service, Parkens Private Hospital, Copenhagen, Denmark A D Sciascia, Shoulder Center of Kentucky, 1221 South Broadway, Lexington, KY 40504;

1.

Correspondence to

[email protected]

Received 13 March 2013 Accepted 13 March 2013 Published Online First 11 April 2013

Abstract The second international consensus conference on the scapula was held in Lexington Kentucky. The purpose of the conference was to update, present and discuss the accumulated knowledge regarding scapular involvement in various shoulder injuries and highlight the clinical implications for the evaluation and treatment of shoulder injuries. The areas covered included the scapula and shoulder injury, the scapula and sports participation, clinical evaluation and interventions and known outcomes. Major conclusions were (1) scapular dyskinesis is present in a high percentage of most shoulder injuries; (2) the exact role of the dyskinesis in creating or exacerbating shoulder dysfunction is not clearly defined; (3) shoulder impingement symptoms are particularly affected by scapular dyskinesis; (4) scapular dyskinesis is most aptly viewed as a potential impairment to shoulder function; (5) treatment strategies for shoulder injury can be more effectively implemented by evaluation of the dyskinesis; (6) a reliable observational clinical evaluation method for dyskinesis is available and (7) rehabilitation programmes to restore scapular position and motion can be effective within a more comprehensive shoulder rehabilitation programme