Shoulder joint kinetics and pathology in manual wheelchair users
Introduction
It is well documented that manual wheelchair users (MWUs) with paraplegia have a high prevalence of shoulder pain and injury (Ballinger et al., 2000, Bayley et al., 1987, Boninger et al., 2001, Escobedo et al., 1997, Lal, 1998, Nichols et al., 1979, Pentland and Twomey, 1991, Sie et al., 1992, Subbarao et al., 1995). Estimates of shoulder pain among manual wheelchair users with paraplegia range from 30% (Ballinger et al., 2000) to 73% (Pentland and Twomey, 1991). A recent review article noted that shoulder pain is often a result of musculoskeletal pathology (Dyson-Hudson and Kirshblum, 2004). Another study reported that the acromioclavicular joint of the shoulder is the most susceptible to degenerative changes (Lal, 1998). MWUs rely on their upper extremity for independent mobility and other critical functions, and thus shoulder pain can be debilitating. One study found that pain was the only factor correlated with lower quality-of-life scores (Lundqvist et al., 1991).
“Overuse syndrome” has been described as one potential cause for pain in MWUs (Bayley et al., 1987, Nichols et al., 1979, Subbarao et al., 1995). Manual wheelchair propulsion places repeated loads on the upper limbs, with a stroke cycle time of less than a second. The shoulder joint experiences loading throughout the propulsion cycle (Cooper et al., 1999, Finley et al., 2004, Kulig et al., 1998, Mulroy et al., 2005, Rodgers et al., 1994). Ergonomics literature has previously identified a link between repetitive loading tasks and musculoskeletal disorders (Andersen et al., 2003, Frost et al., 2002, Leclerc et al., 2004, NIOSH, 1997). In a report of musculoskeletal disorders in the workplace, the National Institute for Occupational Safety and Health defined repetitive activities for the shoulder as activities that involve cyclical flexion, extension, abduction, or rotation of the shoulder joint (NIOSH, 1997). Wheelchair propulsion, while not an occupational task, fits this definition. The effects of repetition can be magnified when combined with awkward postures or loading of the upper extremity such as occurs in wheelchair propulsion (Andersen et al., 2002, Frost et al., 2002, NIOSH, 1997).
It is important to understand what biomechanical factors may predispose individuals to musculoskeletal shoulder pathology so that interventions can be developed. Task performance modification based on ergonomic analysis has proven effective in reducing risk factors for pain and upper extremity pathology in various work settings (Carson, 1994, Chatterjee, 1992, Orgel et al., 1992). Additionally, research has shown that many interventions can be applied to alter propulsion biomechanics (Boninger et al., 2005).
Previous studies have reported shoulder joint forces and moments during propulsion (Cooper et al., 1999, Finley et al., 2004, Kulig et al., 1998, Mulroy et al., 2005, Rodgers et al., 1994), but none have investigated a relationship to shoulder pathology. Since shoulder pain and injury are so common among MWUs, we hope to elucidate biomechanical risk factors for shoulder injury so that potential interventions can be developed. The goal of this study was to calculate shoulder forces and moments during two speeds of manual wheelchair propulsion and determine if biomechanics were related to shoulder pathology. We hypothesized that higher shoulder forces and moments during wheelchair propulsion would be correlated to a higher incidence of shoulder pathology as measured by physical examination and magnetic resonance imaging (MRI).
Section snippets
Subjects
Subjects were recruited from two primary sources: wheelchair vendors and discharge records from a large inpatient spinal cord injury (SCI) rehabilitation unit. A letter was sent to all potential subjects stating the purpose of the study and asking them to contact the laboratory if they wished to participate in the study. This recruiting method allowed us to identify all individuals with SCI, not just those currently being followed through regular clinic visits. The study was approved by our
Subjects
Thirty-three individuals, 23 males and 10 females, participated in this study. The subjects had an average height and mass of 1.74(SD = 0.1) m and 75.6(SD = 15.6) kg respectively. All subjects were between 20 and 70 years old and the average age of the group was 37.8(SD = 11.2) years. The average time since injury to the test date was 12.4(SD = 6.1) years ranging from 1 to 25 years. Only 4 out of 33 subjects reported experiencing pain while propelling their wheelchair in the month prior to testing.
Discussion
To our knowledge, this is largest study to investigate shoulder kinetics during wheelchair propulsion, and the first study to examine the relationship between kinetics and pathology. Our kinetic results are in general agreement with previous studies (Finley et al., 2004, Kulig et al., 1998, Mulroy et al., 2005). Kulig et al. reported significant increases in shoulder forces and moments with faster speed (Kulig et al., 1998). They also observed the same directional force and moment components
Conclusions
Individuals who experienced higher directional shoulder forces and moments were more likely to exhibit coracoacromial arch pathology on MRI and discomfort during a physical exam. Therefore, researchers and clinicians should work to reduce the forces and moments experienced at the shoulder during wheelchair propulsion. The potential exists to modify wheelchair design and set up or propulsion biomechanics in order to reduce the force required to propel the wheelchair, thereby reducing the loading
Acknowledgements
This research was supported by the National Institute on Disability and Rehabilitation Research (Grant # H133A011107), the Veterans Affairs Rehabilitation Research and Development Center (Grant # B3057R and B3142C), and a National Science Foundation Graduate Research Fellowship.
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