Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Disclosures
Zachary Staats OTR and Kristen Fiola PT DPT
have no financial interest or relationships to disclose
Meet Your Presenters
Objectives
bull Describe the components of the mat evaluation to better determine a clientrsquos seating and positioning needs related tondash Promoting participation in functional activitiesndash Promoting neutral alignment of the pelvis spine shoulders head and
neckndash Reducing the risk of future spinal deformities and upper extremity
overuse injuriesbull Discuss the differences between standard lightweight and ultra-lightweight
manual wheelchair frames and how these differences impact upper limb preservation
bull Describe various wheelchair accessories with respect to impact on seated posture function and upper limb preservation
bull Identify optimal wheelchair configuration as defined by the Clinical Practice Guidelines for Preservation of Upper Limb Function Following Spinal Cord Injury
You Got This One
Whose Job Is It
Interdisciplinary Approach
bull Ownership of wheelchair seating and positioning varies between facilities
bull Both OT and PT provide valuable input regarding a clientrsquos seating and mobility needs
Whatrsquos the Big Deal
bull Shift in Biomechanics
bull Function
bull Self-Identity
ANDhellip
The client spends an awful lot of time in that thing
The Journey Beginshellip
Donrsquot forget to bring the client with you
Educate educate educate
Seating and Positioning
bull Every wheelchair user is unique physically and psychologically
bull Environments varybull Needs of the wheelchair users varybull Each combination of user and wheelchair
is new and thus always a challengebull This is true for ANY long term wheelchair
user
How Should One Sit
bull Pelvis in neutral or slight anterior pelvic tiltbull Natural spinal curvesbull Shoulder girdle above pelvic girdlebull Head balanced and aligned in midlinebull Thighsfemurs loadedbull Feet supported and loaded
How Should One Sit
bull Considerationsndash Stabilityndash Pressure distributionndash Ability to lean forwardndash Variationndash Freedom of the feetndash Safety and Security
bull Which of these considerations impact function
Client Interview
bull Comprehensive Medical and Surgical Historybull Cognitionbull Visualperceptual deficitsbull Occupational profile
ndash Life roles and responsibilitiesndash Self-management skillsndash Routines
bull Environmental Assessmentbull Vocational Demandsbull Ability to maintain recommended equipment
The Mat Evaluation
bull Observe the patientrsquos movement ndash Transfersndash Transitional movement
bull Perform a comprehensive assessment in sitting and supine
bull Attempt to position the clientrsquos pelvis and trunk as close to neutral as possible prior to beginning your assessment
The Mat Evaluation
bull Pelvic Alignmentndash Obliquityndash Tiltndash Rotation
bull Trunk Alignmentndash Kyphosisndash Lordosisndash Scoliosisndash Trunk rotation
The Mat Evaluation
bull Shouldersndash Roundedndash Internally rotated
bull Scapulaendash Abductionadductionndash Upwarddownward rotationndash Elevationdepressionndash Winging and tipping
bull Head Alignment ndash Forward headndash Rotationndash Lateral Flexion
The Mat Evaluation
bull Lower Extremity ROMndash Hip flexionndash Hip abductionndash Hip internalexternal rotationndash Knee flexionextensionndash Dorsiflexionplantar-flexion ndash Inversioneversion
bull Remember that you are examining ROM available for seated posture
The Mat Evaluation
The Mat Evaluation
bull Contractures ndash fixed vs flexiblebull Trunk stability and mobilitybull Hypertonicitybull Pain influenced by seated posturebull Muscle strength in relation to maneuvering
a wheelchair and changing position
The Mat Evaluation
bull Place the patient at the edge of the mat as close to 90-90-90 as possible
bull Measurementsndash Seat to top of headndash Seat to top of shouldersndash Seat to axillandash Seat to elbowndash Seat to inferior angle of scapulandash Head widthndash Shoulder widthndash Chest widthndash Hip widthndash Back of hip to back of kneendash Bottom of heel to back of kneendash Foot length
Wheelchair Frame Selection
ldquoProvide manual wheelchair users with a high-strength fully
customizable manual wheelchair made of the lightest possible
materialrdquo
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care
Professionals
Wheelchair Frame Selection
Lightweight Wheelchair (K0003) High-StrengthLightweight Wheelchair (K0004)
Recliner Wheelchair
Wheelchair Frame Selection
The Ultra Lightweight Wheelchair (K0005)
Ultra Lightweight Wheelchair ndashTitanium (K0009)
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Disclosures
Zachary Staats OTR and Kristen Fiola PT DPT
have no financial interest or relationships to disclose
Meet Your Presenters
Objectives
bull Describe the components of the mat evaluation to better determine a clientrsquos seating and positioning needs related tondash Promoting participation in functional activitiesndash Promoting neutral alignment of the pelvis spine shoulders head and
neckndash Reducing the risk of future spinal deformities and upper extremity
overuse injuriesbull Discuss the differences between standard lightweight and ultra-lightweight
manual wheelchair frames and how these differences impact upper limb preservation
bull Describe various wheelchair accessories with respect to impact on seated posture function and upper limb preservation
bull Identify optimal wheelchair configuration as defined by the Clinical Practice Guidelines for Preservation of Upper Limb Function Following Spinal Cord Injury
You Got This One
Whose Job Is It
Interdisciplinary Approach
bull Ownership of wheelchair seating and positioning varies between facilities
bull Both OT and PT provide valuable input regarding a clientrsquos seating and mobility needs
Whatrsquos the Big Deal
bull Shift in Biomechanics
bull Function
bull Self-Identity
ANDhellip
The client spends an awful lot of time in that thing
The Journey Beginshellip
Donrsquot forget to bring the client with you
Educate educate educate
Seating and Positioning
bull Every wheelchair user is unique physically and psychologically
bull Environments varybull Needs of the wheelchair users varybull Each combination of user and wheelchair
is new and thus always a challengebull This is true for ANY long term wheelchair
user
How Should One Sit
bull Pelvis in neutral or slight anterior pelvic tiltbull Natural spinal curvesbull Shoulder girdle above pelvic girdlebull Head balanced and aligned in midlinebull Thighsfemurs loadedbull Feet supported and loaded
How Should One Sit
bull Considerationsndash Stabilityndash Pressure distributionndash Ability to lean forwardndash Variationndash Freedom of the feetndash Safety and Security
bull Which of these considerations impact function
Client Interview
bull Comprehensive Medical and Surgical Historybull Cognitionbull Visualperceptual deficitsbull Occupational profile
ndash Life roles and responsibilitiesndash Self-management skillsndash Routines
bull Environmental Assessmentbull Vocational Demandsbull Ability to maintain recommended equipment
The Mat Evaluation
bull Observe the patientrsquos movement ndash Transfersndash Transitional movement
bull Perform a comprehensive assessment in sitting and supine
bull Attempt to position the clientrsquos pelvis and trunk as close to neutral as possible prior to beginning your assessment
The Mat Evaluation
bull Pelvic Alignmentndash Obliquityndash Tiltndash Rotation
bull Trunk Alignmentndash Kyphosisndash Lordosisndash Scoliosisndash Trunk rotation
The Mat Evaluation
bull Shouldersndash Roundedndash Internally rotated
bull Scapulaendash Abductionadductionndash Upwarddownward rotationndash Elevationdepressionndash Winging and tipping
bull Head Alignment ndash Forward headndash Rotationndash Lateral Flexion
The Mat Evaluation
bull Lower Extremity ROMndash Hip flexionndash Hip abductionndash Hip internalexternal rotationndash Knee flexionextensionndash Dorsiflexionplantar-flexion ndash Inversioneversion
bull Remember that you are examining ROM available for seated posture
The Mat Evaluation
The Mat Evaluation
bull Contractures ndash fixed vs flexiblebull Trunk stability and mobilitybull Hypertonicitybull Pain influenced by seated posturebull Muscle strength in relation to maneuvering
a wheelchair and changing position
The Mat Evaluation
bull Place the patient at the edge of the mat as close to 90-90-90 as possible
bull Measurementsndash Seat to top of headndash Seat to top of shouldersndash Seat to axillandash Seat to elbowndash Seat to inferior angle of scapulandash Head widthndash Shoulder widthndash Chest widthndash Hip widthndash Back of hip to back of kneendash Bottom of heel to back of kneendash Foot length
Wheelchair Frame Selection
ldquoProvide manual wheelchair users with a high-strength fully
customizable manual wheelchair made of the lightest possible
materialrdquo
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care
Professionals
Wheelchair Frame Selection
Lightweight Wheelchair (K0003) High-StrengthLightweight Wheelchair (K0004)
Recliner Wheelchair
Wheelchair Frame Selection
The Ultra Lightweight Wheelchair (K0005)
Ultra Lightweight Wheelchair ndashTitanium (K0009)
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Meet Your Presenters
Objectives
bull Describe the components of the mat evaluation to better determine a clientrsquos seating and positioning needs related tondash Promoting participation in functional activitiesndash Promoting neutral alignment of the pelvis spine shoulders head and
neckndash Reducing the risk of future spinal deformities and upper extremity
overuse injuriesbull Discuss the differences between standard lightweight and ultra-lightweight
manual wheelchair frames and how these differences impact upper limb preservation
bull Describe various wheelchair accessories with respect to impact on seated posture function and upper limb preservation
bull Identify optimal wheelchair configuration as defined by the Clinical Practice Guidelines for Preservation of Upper Limb Function Following Spinal Cord Injury
You Got This One
Whose Job Is It
Interdisciplinary Approach
bull Ownership of wheelchair seating and positioning varies between facilities
bull Both OT and PT provide valuable input regarding a clientrsquos seating and mobility needs
Whatrsquos the Big Deal
bull Shift in Biomechanics
bull Function
bull Self-Identity
ANDhellip
The client spends an awful lot of time in that thing
The Journey Beginshellip
Donrsquot forget to bring the client with you
Educate educate educate
Seating and Positioning
bull Every wheelchair user is unique physically and psychologically
bull Environments varybull Needs of the wheelchair users varybull Each combination of user and wheelchair
is new and thus always a challengebull This is true for ANY long term wheelchair
user
How Should One Sit
bull Pelvis in neutral or slight anterior pelvic tiltbull Natural spinal curvesbull Shoulder girdle above pelvic girdlebull Head balanced and aligned in midlinebull Thighsfemurs loadedbull Feet supported and loaded
How Should One Sit
bull Considerationsndash Stabilityndash Pressure distributionndash Ability to lean forwardndash Variationndash Freedom of the feetndash Safety and Security
bull Which of these considerations impact function
Client Interview
bull Comprehensive Medical and Surgical Historybull Cognitionbull Visualperceptual deficitsbull Occupational profile
ndash Life roles and responsibilitiesndash Self-management skillsndash Routines
bull Environmental Assessmentbull Vocational Demandsbull Ability to maintain recommended equipment
The Mat Evaluation
bull Observe the patientrsquos movement ndash Transfersndash Transitional movement
bull Perform a comprehensive assessment in sitting and supine
bull Attempt to position the clientrsquos pelvis and trunk as close to neutral as possible prior to beginning your assessment
The Mat Evaluation
bull Pelvic Alignmentndash Obliquityndash Tiltndash Rotation
bull Trunk Alignmentndash Kyphosisndash Lordosisndash Scoliosisndash Trunk rotation
The Mat Evaluation
bull Shouldersndash Roundedndash Internally rotated
bull Scapulaendash Abductionadductionndash Upwarddownward rotationndash Elevationdepressionndash Winging and tipping
bull Head Alignment ndash Forward headndash Rotationndash Lateral Flexion
The Mat Evaluation
bull Lower Extremity ROMndash Hip flexionndash Hip abductionndash Hip internalexternal rotationndash Knee flexionextensionndash Dorsiflexionplantar-flexion ndash Inversioneversion
bull Remember that you are examining ROM available for seated posture
The Mat Evaluation
The Mat Evaluation
bull Contractures ndash fixed vs flexiblebull Trunk stability and mobilitybull Hypertonicitybull Pain influenced by seated posturebull Muscle strength in relation to maneuvering
a wheelchair and changing position
The Mat Evaluation
bull Place the patient at the edge of the mat as close to 90-90-90 as possible
bull Measurementsndash Seat to top of headndash Seat to top of shouldersndash Seat to axillandash Seat to elbowndash Seat to inferior angle of scapulandash Head widthndash Shoulder widthndash Chest widthndash Hip widthndash Back of hip to back of kneendash Bottom of heel to back of kneendash Foot length
Wheelchair Frame Selection
ldquoProvide manual wheelchair users with a high-strength fully
customizable manual wheelchair made of the lightest possible
materialrdquo
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care
Professionals
Wheelchair Frame Selection
Lightweight Wheelchair (K0003) High-StrengthLightweight Wheelchair (K0004)
Recliner Wheelchair
Wheelchair Frame Selection
The Ultra Lightweight Wheelchair (K0005)
Ultra Lightweight Wheelchair ndashTitanium (K0009)
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Objectives
bull Describe the components of the mat evaluation to better determine a clientrsquos seating and positioning needs related tondash Promoting participation in functional activitiesndash Promoting neutral alignment of the pelvis spine shoulders head and
neckndash Reducing the risk of future spinal deformities and upper extremity
overuse injuriesbull Discuss the differences between standard lightweight and ultra-lightweight
manual wheelchair frames and how these differences impact upper limb preservation
bull Describe various wheelchair accessories with respect to impact on seated posture function and upper limb preservation
bull Identify optimal wheelchair configuration as defined by the Clinical Practice Guidelines for Preservation of Upper Limb Function Following Spinal Cord Injury
You Got This One
Whose Job Is It
Interdisciplinary Approach
bull Ownership of wheelchair seating and positioning varies between facilities
bull Both OT and PT provide valuable input regarding a clientrsquos seating and mobility needs
Whatrsquos the Big Deal
bull Shift in Biomechanics
bull Function
bull Self-Identity
ANDhellip
The client spends an awful lot of time in that thing
The Journey Beginshellip
Donrsquot forget to bring the client with you
Educate educate educate
Seating and Positioning
bull Every wheelchair user is unique physically and psychologically
bull Environments varybull Needs of the wheelchair users varybull Each combination of user and wheelchair
is new and thus always a challengebull This is true for ANY long term wheelchair
user
How Should One Sit
bull Pelvis in neutral or slight anterior pelvic tiltbull Natural spinal curvesbull Shoulder girdle above pelvic girdlebull Head balanced and aligned in midlinebull Thighsfemurs loadedbull Feet supported and loaded
How Should One Sit
bull Considerationsndash Stabilityndash Pressure distributionndash Ability to lean forwardndash Variationndash Freedom of the feetndash Safety and Security
bull Which of these considerations impact function
Client Interview
bull Comprehensive Medical and Surgical Historybull Cognitionbull Visualperceptual deficitsbull Occupational profile
ndash Life roles and responsibilitiesndash Self-management skillsndash Routines
bull Environmental Assessmentbull Vocational Demandsbull Ability to maintain recommended equipment
The Mat Evaluation
bull Observe the patientrsquos movement ndash Transfersndash Transitional movement
bull Perform a comprehensive assessment in sitting and supine
bull Attempt to position the clientrsquos pelvis and trunk as close to neutral as possible prior to beginning your assessment
The Mat Evaluation
bull Pelvic Alignmentndash Obliquityndash Tiltndash Rotation
bull Trunk Alignmentndash Kyphosisndash Lordosisndash Scoliosisndash Trunk rotation
The Mat Evaluation
bull Shouldersndash Roundedndash Internally rotated
bull Scapulaendash Abductionadductionndash Upwarddownward rotationndash Elevationdepressionndash Winging and tipping
bull Head Alignment ndash Forward headndash Rotationndash Lateral Flexion
The Mat Evaluation
bull Lower Extremity ROMndash Hip flexionndash Hip abductionndash Hip internalexternal rotationndash Knee flexionextensionndash Dorsiflexionplantar-flexion ndash Inversioneversion
bull Remember that you are examining ROM available for seated posture
The Mat Evaluation
The Mat Evaluation
bull Contractures ndash fixed vs flexiblebull Trunk stability and mobilitybull Hypertonicitybull Pain influenced by seated posturebull Muscle strength in relation to maneuvering
a wheelchair and changing position
The Mat Evaluation
bull Place the patient at the edge of the mat as close to 90-90-90 as possible
bull Measurementsndash Seat to top of headndash Seat to top of shouldersndash Seat to axillandash Seat to elbowndash Seat to inferior angle of scapulandash Head widthndash Shoulder widthndash Chest widthndash Hip widthndash Back of hip to back of kneendash Bottom of heel to back of kneendash Foot length
Wheelchair Frame Selection
ldquoProvide manual wheelchair users with a high-strength fully
customizable manual wheelchair made of the lightest possible
materialrdquo
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care
Professionals
Wheelchair Frame Selection
Lightweight Wheelchair (K0003) High-StrengthLightweight Wheelchair (K0004)
Recliner Wheelchair
Wheelchair Frame Selection
The Ultra Lightweight Wheelchair (K0005)
Ultra Lightweight Wheelchair ndashTitanium (K0009)
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
You Got This One
Whose Job Is It
Interdisciplinary Approach
bull Ownership of wheelchair seating and positioning varies between facilities
bull Both OT and PT provide valuable input regarding a clientrsquos seating and mobility needs
Whatrsquos the Big Deal
bull Shift in Biomechanics
bull Function
bull Self-Identity
ANDhellip
The client spends an awful lot of time in that thing
The Journey Beginshellip
Donrsquot forget to bring the client with you
Educate educate educate
Seating and Positioning
bull Every wheelchair user is unique physically and psychologically
bull Environments varybull Needs of the wheelchair users varybull Each combination of user and wheelchair
is new and thus always a challengebull This is true for ANY long term wheelchair
user
How Should One Sit
bull Pelvis in neutral or slight anterior pelvic tiltbull Natural spinal curvesbull Shoulder girdle above pelvic girdlebull Head balanced and aligned in midlinebull Thighsfemurs loadedbull Feet supported and loaded
How Should One Sit
bull Considerationsndash Stabilityndash Pressure distributionndash Ability to lean forwardndash Variationndash Freedom of the feetndash Safety and Security
bull Which of these considerations impact function
Client Interview
bull Comprehensive Medical and Surgical Historybull Cognitionbull Visualperceptual deficitsbull Occupational profile
ndash Life roles and responsibilitiesndash Self-management skillsndash Routines
bull Environmental Assessmentbull Vocational Demandsbull Ability to maintain recommended equipment
The Mat Evaluation
bull Observe the patientrsquos movement ndash Transfersndash Transitional movement
bull Perform a comprehensive assessment in sitting and supine
bull Attempt to position the clientrsquos pelvis and trunk as close to neutral as possible prior to beginning your assessment
The Mat Evaluation
bull Pelvic Alignmentndash Obliquityndash Tiltndash Rotation
bull Trunk Alignmentndash Kyphosisndash Lordosisndash Scoliosisndash Trunk rotation
The Mat Evaluation
bull Shouldersndash Roundedndash Internally rotated
bull Scapulaendash Abductionadductionndash Upwarddownward rotationndash Elevationdepressionndash Winging and tipping
bull Head Alignment ndash Forward headndash Rotationndash Lateral Flexion
The Mat Evaluation
bull Lower Extremity ROMndash Hip flexionndash Hip abductionndash Hip internalexternal rotationndash Knee flexionextensionndash Dorsiflexionplantar-flexion ndash Inversioneversion
bull Remember that you are examining ROM available for seated posture
The Mat Evaluation
The Mat Evaluation
bull Contractures ndash fixed vs flexiblebull Trunk stability and mobilitybull Hypertonicitybull Pain influenced by seated posturebull Muscle strength in relation to maneuvering
a wheelchair and changing position
The Mat Evaluation
bull Place the patient at the edge of the mat as close to 90-90-90 as possible
bull Measurementsndash Seat to top of headndash Seat to top of shouldersndash Seat to axillandash Seat to elbowndash Seat to inferior angle of scapulandash Head widthndash Shoulder widthndash Chest widthndash Hip widthndash Back of hip to back of kneendash Bottom of heel to back of kneendash Foot length
Wheelchair Frame Selection
ldquoProvide manual wheelchair users with a high-strength fully
customizable manual wheelchair made of the lightest possible
materialrdquo
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care
Professionals
Wheelchair Frame Selection
Lightweight Wheelchair (K0003) High-StrengthLightweight Wheelchair (K0004)
Recliner Wheelchair
Wheelchair Frame Selection
The Ultra Lightweight Wheelchair (K0005)
Ultra Lightweight Wheelchair ndashTitanium (K0009)
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Interdisciplinary Approach
bull Ownership of wheelchair seating and positioning varies between facilities
bull Both OT and PT provide valuable input regarding a clientrsquos seating and mobility needs
Whatrsquos the Big Deal
bull Shift in Biomechanics
bull Function
bull Self-Identity
ANDhellip
The client spends an awful lot of time in that thing
The Journey Beginshellip
Donrsquot forget to bring the client with you
Educate educate educate
Seating and Positioning
bull Every wheelchair user is unique physically and psychologically
bull Environments varybull Needs of the wheelchair users varybull Each combination of user and wheelchair
is new and thus always a challengebull This is true for ANY long term wheelchair
user
How Should One Sit
bull Pelvis in neutral or slight anterior pelvic tiltbull Natural spinal curvesbull Shoulder girdle above pelvic girdlebull Head balanced and aligned in midlinebull Thighsfemurs loadedbull Feet supported and loaded
How Should One Sit
bull Considerationsndash Stabilityndash Pressure distributionndash Ability to lean forwardndash Variationndash Freedom of the feetndash Safety and Security
bull Which of these considerations impact function
Client Interview
bull Comprehensive Medical and Surgical Historybull Cognitionbull Visualperceptual deficitsbull Occupational profile
ndash Life roles and responsibilitiesndash Self-management skillsndash Routines
bull Environmental Assessmentbull Vocational Demandsbull Ability to maintain recommended equipment
The Mat Evaluation
bull Observe the patientrsquos movement ndash Transfersndash Transitional movement
bull Perform a comprehensive assessment in sitting and supine
bull Attempt to position the clientrsquos pelvis and trunk as close to neutral as possible prior to beginning your assessment
The Mat Evaluation
bull Pelvic Alignmentndash Obliquityndash Tiltndash Rotation
bull Trunk Alignmentndash Kyphosisndash Lordosisndash Scoliosisndash Trunk rotation
The Mat Evaluation
bull Shouldersndash Roundedndash Internally rotated
bull Scapulaendash Abductionadductionndash Upwarddownward rotationndash Elevationdepressionndash Winging and tipping
bull Head Alignment ndash Forward headndash Rotationndash Lateral Flexion
The Mat Evaluation
bull Lower Extremity ROMndash Hip flexionndash Hip abductionndash Hip internalexternal rotationndash Knee flexionextensionndash Dorsiflexionplantar-flexion ndash Inversioneversion
bull Remember that you are examining ROM available for seated posture
The Mat Evaluation
The Mat Evaluation
bull Contractures ndash fixed vs flexiblebull Trunk stability and mobilitybull Hypertonicitybull Pain influenced by seated posturebull Muscle strength in relation to maneuvering
a wheelchair and changing position
The Mat Evaluation
bull Place the patient at the edge of the mat as close to 90-90-90 as possible
bull Measurementsndash Seat to top of headndash Seat to top of shouldersndash Seat to axillandash Seat to elbowndash Seat to inferior angle of scapulandash Head widthndash Shoulder widthndash Chest widthndash Hip widthndash Back of hip to back of kneendash Bottom of heel to back of kneendash Foot length
Wheelchair Frame Selection
ldquoProvide manual wheelchair users with a high-strength fully
customizable manual wheelchair made of the lightest possible
materialrdquo
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care
Professionals
Wheelchair Frame Selection
Lightweight Wheelchair (K0003) High-StrengthLightweight Wheelchair (K0004)
Recliner Wheelchair
Wheelchair Frame Selection
The Ultra Lightweight Wheelchair (K0005)
Ultra Lightweight Wheelchair ndashTitanium (K0009)
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Whatrsquos the Big Deal
bull Shift in Biomechanics
bull Function
bull Self-Identity
ANDhellip
The client spends an awful lot of time in that thing
The Journey Beginshellip
Donrsquot forget to bring the client with you
Educate educate educate
Seating and Positioning
bull Every wheelchair user is unique physically and psychologically
bull Environments varybull Needs of the wheelchair users varybull Each combination of user and wheelchair
is new and thus always a challengebull This is true for ANY long term wheelchair
user
How Should One Sit
bull Pelvis in neutral or slight anterior pelvic tiltbull Natural spinal curvesbull Shoulder girdle above pelvic girdlebull Head balanced and aligned in midlinebull Thighsfemurs loadedbull Feet supported and loaded
How Should One Sit
bull Considerationsndash Stabilityndash Pressure distributionndash Ability to lean forwardndash Variationndash Freedom of the feetndash Safety and Security
bull Which of these considerations impact function
Client Interview
bull Comprehensive Medical and Surgical Historybull Cognitionbull Visualperceptual deficitsbull Occupational profile
ndash Life roles and responsibilitiesndash Self-management skillsndash Routines
bull Environmental Assessmentbull Vocational Demandsbull Ability to maintain recommended equipment
The Mat Evaluation
bull Observe the patientrsquos movement ndash Transfersndash Transitional movement
bull Perform a comprehensive assessment in sitting and supine
bull Attempt to position the clientrsquos pelvis and trunk as close to neutral as possible prior to beginning your assessment
The Mat Evaluation
bull Pelvic Alignmentndash Obliquityndash Tiltndash Rotation
bull Trunk Alignmentndash Kyphosisndash Lordosisndash Scoliosisndash Trunk rotation
The Mat Evaluation
bull Shouldersndash Roundedndash Internally rotated
bull Scapulaendash Abductionadductionndash Upwarddownward rotationndash Elevationdepressionndash Winging and tipping
bull Head Alignment ndash Forward headndash Rotationndash Lateral Flexion
The Mat Evaluation
bull Lower Extremity ROMndash Hip flexionndash Hip abductionndash Hip internalexternal rotationndash Knee flexionextensionndash Dorsiflexionplantar-flexion ndash Inversioneversion
bull Remember that you are examining ROM available for seated posture
The Mat Evaluation
The Mat Evaluation
bull Contractures ndash fixed vs flexiblebull Trunk stability and mobilitybull Hypertonicitybull Pain influenced by seated posturebull Muscle strength in relation to maneuvering
a wheelchair and changing position
The Mat Evaluation
bull Place the patient at the edge of the mat as close to 90-90-90 as possible
bull Measurementsndash Seat to top of headndash Seat to top of shouldersndash Seat to axillandash Seat to elbowndash Seat to inferior angle of scapulandash Head widthndash Shoulder widthndash Chest widthndash Hip widthndash Back of hip to back of kneendash Bottom of heel to back of kneendash Foot length
Wheelchair Frame Selection
ldquoProvide manual wheelchair users with a high-strength fully
customizable manual wheelchair made of the lightest possible
materialrdquo
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care
Professionals
Wheelchair Frame Selection
Lightweight Wheelchair (K0003) High-StrengthLightweight Wheelchair (K0004)
Recliner Wheelchair
Wheelchair Frame Selection
The Ultra Lightweight Wheelchair (K0005)
Ultra Lightweight Wheelchair ndashTitanium (K0009)
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
ANDhellip
The client spends an awful lot of time in that thing
The Journey Beginshellip
Donrsquot forget to bring the client with you
Educate educate educate
Seating and Positioning
bull Every wheelchair user is unique physically and psychologically
bull Environments varybull Needs of the wheelchair users varybull Each combination of user and wheelchair
is new and thus always a challengebull This is true for ANY long term wheelchair
user
How Should One Sit
bull Pelvis in neutral or slight anterior pelvic tiltbull Natural spinal curvesbull Shoulder girdle above pelvic girdlebull Head balanced and aligned in midlinebull Thighsfemurs loadedbull Feet supported and loaded
How Should One Sit
bull Considerationsndash Stabilityndash Pressure distributionndash Ability to lean forwardndash Variationndash Freedom of the feetndash Safety and Security
bull Which of these considerations impact function
Client Interview
bull Comprehensive Medical and Surgical Historybull Cognitionbull Visualperceptual deficitsbull Occupational profile
ndash Life roles and responsibilitiesndash Self-management skillsndash Routines
bull Environmental Assessmentbull Vocational Demandsbull Ability to maintain recommended equipment
The Mat Evaluation
bull Observe the patientrsquos movement ndash Transfersndash Transitional movement
bull Perform a comprehensive assessment in sitting and supine
bull Attempt to position the clientrsquos pelvis and trunk as close to neutral as possible prior to beginning your assessment
The Mat Evaluation
bull Pelvic Alignmentndash Obliquityndash Tiltndash Rotation
bull Trunk Alignmentndash Kyphosisndash Lordosisndash Scoliosisndash Trunk rotation
The Mat Evaluation
bull Shouldersndash Roundedndash Internally rotated
bull Scapulaendash Abductionadductionndash Upwarddownward rotationndash Elevationdepressionndash Winging and tipping
bull Head Alignment ndash Forward headndash Rotationndash Lateral Flexion
The Mat Evaluation
bull Lower Extremity ROMndash Hip flexionndash Hip abductionndash Hip internalexternal rotationndash Knee flexionextensionndash Dorsiflexionplantar-flexion ndash Inversioneversion
bull Remember that you are examining ROM available for seated posture
The Mat Evaluation
The Mat Evaluation
bull Contractures ndash fixed vs flexiblebull Trunk stability and mobilitybull Hypertonicitybull Pain influenced by seated posturebull Muscle strength in relation to maneuvering
a wheelchair and changing position
The Mat Evaluation
bull Place the patient at the edge of the mat as close to 90-90-90 as possible
bull Measurementsndash Seat to top of headndash Seat to top of shouldersndash Seat to axillandash Seat to elbowndash Seat to inferior angle of scapulandash Head widthndash Shoulder widthndash Chest widthndash Hip widthndash Back of hip to back of kneendash Bottom of heel to back of kneendash Foot length
Wheelchair Frame Selection
ldquoProvide manual wheelchair users with a high-strength fully
customizable manual wheelchair made of the lightest possible
materialrdquo
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care
Professionals
Wheelchair Frame Selection
Lightweight Wheelchair (K0003) High-StrengthLightweight Wheelchair (K0004)
Recliner Wheelchair
Wheelchair Frame Selection
The Ultra Lightweight Wheelchair (K0005)
Ultra Lightweight Wheelchair ndashTitanium (K0009)
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The Journey Beginshellip
Donrsquot forget to bring the client with you
Educate educate educate
Seating and Positioning
bull Every wheelchair user is unique physically and psychologically
bull Environments varybull Needs of the wheelchair users varybull Each combination of user and wheelchair
is new and thus always a challengebull This is true for ANY long term wheelchair
user
How Should One Sit
bull Pelvis in neutral or slight anterior pelvic tiltbull Natural spinal curvesbull Shoulder girdle above pelvic girdlebull Head balanced and aligned in midlinebull Thighsfemurs loadedbull Feet supported and loaded
How Should One Sit
bull Considerationsndash Stabilityndash Pressure distributionndash Ability to lean forwardndash Variationndash Freedom of the feetndash Safety and Security
bull Which of these considerations impact function
Client Interview
bull Comprehensive Medical and Surgical Historybull Cognitionbull Visualperceptual deficitsbull Occupational profile
ndash Life roles and responsibilitiesndash Self-management skillsndash Routines
bull Environmental Assessmentbull Vocational Demandsbull Ability to maintain recommended equipment
The Mat Evaluation
bull Observe the patientrsquos movement ndash Transfersndash Transitional movement
bull Perform a comprehensive assessment in sitting and supine
bull Attempt to position the clientrsquos pelvis and trunk as close to neutral as possible prior to beginning your assessment
The Mat Evaluation
bull Pelvic Alignmentndash Obliquityndash Tiltndash Rotation
bull Trunk Alignmentndash Kyphosisndash Lordosisndash Scoliosisndash Trunk rotation
The Mat Evaluation
bull Shouldersndash Roundedndash Internally rotated
bull Scapulaendash Abductionadductionndash Upwarddownward rotationndash Elevationdepressionndash Winging and tipping
bull Head Alignment ndash Forward headndash Rotationndash Lateral Flexion
The Mat Evaluation
bull Lower Extremity ROMndash Hip flexionndash Hip abductionndash Hip internalexternal rotationndash Knee flexionextensionndash Dorsiflexionplantar-flexion ndash Inversioneversion
bull Remember that you are examining ROM available for seated posture
The Mat Evaluation
The Mat Evaluation
bull Contractures ndash fixed vs flexiblebull Trunk stability and mobilitybull Hypertonicitybull Pain influenced by seated posturebull Muscle strength in relation to maneuvering
a wheelchair and changing position
The Mat Evaluation
bull Place the patient at the edge of the mat as close to 90-90-90 as possible
bull Measurementsndash Seat to top of headndash Seat to top of shouldersndash Seat to axillandash Seat to elbowndash Seat to inferior angle of scapulandash Head widthndash Shoulder widthndash Chest widthndash Hip widthndash Back of hip to back of kneendash Bottom of heel to back of kneendash Foot length
Wheelchair Frame Selection
ldquoProvide manual wheelchair users with a high-strength fully
customizable manual wheelchair made of the lightest possible
materialrdquo
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care
Professionals
Wheelchair Frame Selection
Lightweight Wheelchair (K0003) High-StrengthLightweight Wheelchair (K0004)
Recliner Wheelchair
Wheelchair Frame Selection
The Ultra Lightweight Wheelchair (K0005)
Ultra Lightweight Wheelchair ndashTitanium (K0009)
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Seating and Positioning
bull Every wheelchair user is unique physically and psychologically
bull Environments varybull Needs of the wheelchair users varybull Each combination of user and wheelchair
is new and thus always a challengebull This is true for ANY long term wheelchair
user
How Should One Sit
bull Pelvis in neutral or slight anterior pelvic tiltbull Natural spinal curvesbull Shoulder girdle above pelvic girdlebull Head balanced and aligned in midlinebull Thighsfemurs loadedbull Feet supported and loaded
How Should One Sit
bull Considerationsndash Stabilityndash Pressure distributionndash Ability to lean forwardndash Variationndash Freedom of the feetndash Safety and Security
bull Which of these considerations impact function
Client Interview
bull Comprehensive Medical and Surgical Historybull Cognitionbull Visualperceptual deficitsbull Occupational profile
ndash Life roles and responsibilitiesndash Self-management skillsndash Routines
bull Environmental Assessmentbull Vocational Demandsbull Ability to maintain recommended equipment
The Mat Evaluation
bull Observe the patientrsquos movement ndash Transfersndash Transitional movement
bull Perform a comprehensive assessment in sitting and supine
bull Attempt to position the clientrsquos pelvis and trunk as close to neutral as possible prior to beginning your assessment
The Mat Evaluation
bull Pelvic Alignmentndash Obliquityndash Tiltndash Rotation
bull Trunk Alignmentndash Kyphosisndash Lordosisndash Scoliosisndash Trunk rotation
The Mat Evaluation
bull Shouldersndash Roundedndash Internally rotated
bull Scapulaendash Abductionadductionndash Upwarddownward rotationndash Elevationdepressionndash Winging and tipping
bull Head Alignment ndash Forward headndash Rotationndash Lateral Flexion
The Mat Evaluation
bull Lower Extremity ROMndash Hip flexionndash Hip abductionndash Hip internalexternal rotationndash Knee flexionextensionndash Dorsiflexionplantar-flexion ndash Inversioneversion
bull Remember that you are examining ROM available for seated posture
The Mat Evaluation
The Mat Evaluation
bull Contractures ndash fixed vs flexiblebull Trunk stability and mobilitybull Hypertonicitybull Pain influenced by seated posturebull Muscle strength in relation to maneuvering
a wheelchair and changing position
The Mat Evaluation
bull Place the patient at the edge of the mat as close to 90-90-90 as possible
bull Measurementsndash Seat to top of headndash Seat to top of shouldersndash Seat to axillandash Seat to elbowndash Seat to inferior angle of scapulandash Head widthndash Shoulder widthndash Chest widthndash Hip widthndash Back of hip to back of kneendash Bottom of heel to back of kneendash Foot length
Wheelchair Frame Selection
ldquoProvide manual wheelchair users with a high-strength fully
customizable manual wheelchair made of the lightest possible
materialrdquo
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care
Professionals
Wheelchair Frame Selection
Lightweight Wheelchair (K0003) High-StrengthLightweight Wheelchair (K0004)
Recliner Wheelchair
Wheelchair Frame Selection
The Ultra Lightweight Wheelchair (K0005)
Ultra Lightweight Wheelchair ndashTitanium (K0009)
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
How Should One Sit
bull Pelvis in neutral or slight anterior pelvic tiltbull Natural spinal curvesbull Shoulder girdle above pelvic girdlebull Head balanced and aligned in midlinebull Thighsfemurs loadedbull Feet supported and loaded
How Should One Sit
bull Considerationsndash Stabilityndash Pressure distributionndash Ability to lean forwardndash Variationndash Freedom of the feetndash Safety and Security
bull Which of these considerations impact function
Client Interview
bull Comprehensive Medical and Surgical Historybull Cognitionbull Visualperceptual deficitsbull Occupational profile
ndash Life roles and responsibilitiesndash Self-management skillsndash Routines
bull Environmental Assessmentbull Vocational Demandsbull Ability to maintain recommended equipment
The Mat Evaluation
bull Observe the patientrsquos movement ndash Transfersndash Transitional movement
bull Perform a comprehensive assessment in sitting and supine
bull Attempt to position the clientrsquos pelvis and trunk as close to neutral as possible prior to beginning your assessment
The Mat Evaluation
bull Pelvic Alignmentndash Obliquityndash Tiltndash Rotation
bull Trunk Alignmentndash Kyphosisndash Lordosisndash Scoliosisndash Trunk rotation
The Mat Evaluation
bull Shouldersndash Roundedndash Internally rotated
bull Scapulaendash Abductionadductionndash Upwarddownward rotationndash Elevationdepressionndash Winging and tipping
bull Head Alignment ndash Forward headndash Rotationndash Lateral Flexion
The Mat Evaluation
bull Lower Extremity ROMndash Hip flexionndash Hip abductionndash Hip internalexternal rotationndash Knee flexionextensionndash Dorsiflexionplantar-flexion ndash Inversioneversion
bull Remember that you are examining ROM available for seated posture
The Mat Evaluation
The Mat Evaluation
bull Contractures ndash fixed vs flexiblebull Trunk stability and mobilitybull Hypertonicitybull Pain influenced by seated posturebull Muscle strength in relation to maneuvering
a wheelchair and changing position
The Mat Evaluation
bull Place the patient at the edge of the mat as close to 90-90-90 as possible
bull Measurementsndash Seat to top of headndash Seat to top of shouldersndash Seat to axillandash Seat to elbowndash Seat to inferior angle of scapulandash Head widthndash Shoulder widthndash Chest widthndash Hip widthndash Back of hip to back of kneendash Bottom of heel to back of kneendash Foot length
Wheelchair Frame Selection
ldquoProvide manual wheelchair users with a high-strength fully
customizable manual wheelchair made of the lightest possible
materialrdquo
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care
Professionals
Wheelchair Frame Selection
Lightweight Wheelchair (K0003) High-StrengthLightweight Wheelchair (K0004)
Recliner Wheelchair
Wheelchair Frame Selection
The Ultra Lightweight Wheelchair (K0005)
Ultra Lightweight Wheelchair ndashTitanium (K0009)
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
How Should One Sit
bull Considerationsndash Stabilityndash Pressure distributionndash Ability to lean forwardndash Variationndash Freedom of the feetndash Safety and Security
bull Which of these considerations impact function
Client Interview
bull Comprehensive Medical and Surgical Historybull Cognitionbull Visualperceptual deficitsbull Occupational profile
ndash Life roles and responsibilitiesndash Self-management skillsndash Routines
bull Environmental Assessmentbull Vocational Demandsbull Ability to maintain recommended equipment
The Mat Evaluation
bull Observe the patientrsquos movement ndash Transfersndash Transitional movement
bull Perform a comprehensive assessment in sitting and supine
bull Attempt to position the clientrsquos pelvis and trunk as close to neutral as possible prior to beginning your assessment
The Mat Evaluation
bull Pelvic Alignmentndash Obliquityndash Tiltndash Rotation
bull Trunk Alignmentndash Kyphosisndash Lordosisndash Scoliosisndash Trunk rotation
The Mat Evaluation
bull Shouldersndash Roundedndash Internally rotated
bull Scapulaendash Abductionadductionndash Upwarddownward rotationndash Elevationdepressionndash Winging and tipping
bull Head Alignment ndash Forward headndash Rotationndash Lateral Flexion
The Mat Evaluation
bull Lower Extremity ROMndash Hip flexionndash Hip abductionndash Hip internalexternal rotationndash Knee flexionextensionndash Dorsiflexionplantar-flexion ndash Inversioneversion
bull Remember that you are examining ROM available for seated posture
The Mat Evaluation
The Mat Evaluation
bull Contractures ndash fixed vs flexiblebull Trunk stability and mobilitybull Hypertonicitybull Pain influenced by seated posturebull Muscle strength in relation to maneuvering
a wheelchair and changing position
The Mat Evaluation
bull Place the patient at the edge of the mat as close to 90-90-90 as possible
bull Measurementsndash Seat to top of headndash Seat to top of shouldersndash Seat to axillandash Seat to elbowndash Seat to inferior angle of scapulandash Head widthndash Shoulder widthndash Chest widthndash Hip widthndash Back of hip to back of kneendash Bottom of heel to back of kneendash Foot length
Wheelchair Frame Selection
ldquoProvide manual wheelchair users with a high-strength fully
customizable manual wheelchair made of the lightest possible
materialrdquo
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care
Professionals
Wheelchair Frame Selection
Lightweight Wheelchair (K0003) High-StrengthLightweight Wheelchair (K0004)
Recliner Wheelchair
Wheelchair Frame Selection
The Ultra Lightweight Wheelchair (K0005)
Ultra Lightweight Wheelchair ndashTitanium (K0009)
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Client Interview
bull Comprehensive Medical and Surgical Historybull Cognitionbull Visualperceptual deficitsbull Occupational profile
ndash Life roles and responsibilitiesndash Self-management skillsndash Routines
bull Environmental Assessmentbull Vocational Demandsbull Ability to maintain recommended equipment
The Mat Evaluation
bull Observe the patientrsquos movement ndash Transfersndash Transitional movement
bull Perform a comprehensive assessment in sitting and supine
bull Attempt to position the clientrsquos pelvis and trunk as close to neutral as possible prior to beginning your assessment
The Mat Evaluation
bull Pelvic Alignmentndash Obliquityndash Tiltndash Rotation
bull Trunk Alignmentndash Kyphosisndash Lordosisndash Scoliosisndash Trunk rotation
The Mat Evaluation
bull Shouldersndash Roundedndash Internally rotated
bull Scapulaendash Abductionadductionndash Upwarddownward rotationndash Elevationdepressionndash Winging and tipping
bull Head Alignment ndash Forward headndash Rotationndash Lateral Flexion
The Mat Evaluation
bull Lower Extremity ROMndash Hip flexionndash Hip abductionndash Hip internalexternal rotationndash Knee flexionextensionndash Dorsiflexionplantar-flexion ndash Inversioneversion
bull Remember that you are examining ROM available for seated posture
The Mat Evaluation
The Mat Evaluation
bull Contractures ndash fixed vs flexiblebull Trunk stability and mobilitybull Hypertonicitybull Pain influenced by seated posturebull Muscle strength in relation to maneuvering
a wheelchair and changing position
The Mat Evaluation
bull Place the patient at the edge of the mat as close to 90-90-90 as possible
bull Measurementsndash Seat to top of headndash Seat to top of shouldersndash Seat to axillandash Seat to elbowndash Seat to inferior angle of scapulandash Head widthndash Shoulder widthndash Chest widthndash Hip widthndash Back of hip to back of kneendash Bottom of heel to back of kneendash Foot length
Wheelchair Frame Selection
ldquoProvide manual wheelchair users with a high-strength fully
customizable manual wheelchair made of the lightest possible
materialrdquo
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care
Professionals
Wheelchair Frame Selection
Lightweight Wheelchair (K0003) High-StrengthLightweight Wheelchair (K0004)
Recliner Wheelchair
Wheelchair Frame Selection
The Ultra Lightweight Wheelchair (K0005)
Ultra Lightweight Wheelchair ndashTitanium (K0009)
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The Mat Evaluation
bull Observe the patientrsquos movement ndash Transfersndash Transitional movement
bull Perform a comprehensive assessment in sitting and supine
bull Attempt to position the clientrsquos pelvis and trunk as close to neutral as possible prior to beginning your assessment
The Mat Evaluation
bull Pelvic Alignmentndash Obliquityndash Tiltndash Rotation
bull Trunk Alignmentndash Kyphosisndash Lordosisndash Scoliosisndash Trunk rotation
The Mat Evaluation
bull Shouldersndash Roundedndash Internally rotated
bull Scapulaendash Abductionadductionndash Upwarddownward rotationndash Elevationdepressionndash Winging and tipping
bull Head Alignment ndash Forward headndash Rotationndash Lateral Flexion
The Mat Evaluation
bull Lower Extremity ROMndash Hip flexionndash Hip abductionndash Hip internalexternal rotationndash Knee flexionextensionndash Dorsiflexionplantar-flexion ndash Inversioneversion
bull Remember that you are examining ROM available for seated posture
The Mat Evaluation
The Mat Evaluation
bull Contractures ndash fixed vs flexiblebull Trunk stability and mobilitybull Hypertonicitybull Pain influenced by seated posturebull Muscle strength in relation to maneuvering
a wheelchair and changing position
The Mat Evaluation
bull Place the patient at the edge of the mat as close to 90-90-90 as possible
bull Measurementsndash Seat to top of headndash Seat to top of shouldersndash Seat to axillandash Seat to elbowndash Seat to inferior angle of scapulandash Head widthndash Shoulder widthndash Chest widthndash Hip widthndash Back of hip to back of kneendash Bottom of heel to back of kneendash Foot length
Wheelchair Frame Selection
ldquoProvide manual wheelchair users with a high-strength fully
customizable manual wheelchair made of the lightest possible
materialrdquo
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care
Professionals
Wheelchair Frame Selection
Lightweight Wheelchair (K0003) High-StrengthLightweight Wheelchair (K0004)
Recliner Wheelchair
Wheelchair Frame Selection
The Ultra Lightweight Wheelchair (K0005)
Ultra Lightweight Wheelchair ndashTitanium (K0009)
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The Mat Evaluation
bull Pelvic Alignmentndash Obliquityndash Tiltndash Rotation
bull Trunk Alignmentndash Kyphosisndash Lordosisndash Scoliosisndash Trunk rotation
The Mat Evaluation
bull Shouldersndash Roundedndash Internally rotated
bull Scapulaendash Abductionadductionndash Upwarddownward rotationndash Elevationdepressionndash Winging and tipping
bull Head Alignment ndash Forward headndash Rotationndash Lateral Flexion
The Mat Evaluation
bull Lower Extremity ROMndash Hip flexionndash Hip abductionndash Hip internalexternal rotationndash Knee flexionextensionndash Dorsiflexionplantar-flexion ndash Inversioneversion
bull Remember that you are examining ROM available for seated posture
The Mat Evaluation
The Mat Evaluation
bull Contractures ndash fixed vs flexiblebull Trunk stability and mobilitybull Hypertonicitybull Pain influenced by seated posturebull Muscle strength in relation to maneuvering
a wheelchair and changing position
The Mat Evaluation
bull Place the patient at the edge of the mat as close to 90-90-90 as possible
bull Measurementsndash Seat to top of headndash Seat to top of shouldersndash Seat to axillandash Seat to elbowndash Seat to inferior angle of scapulandash Head widthndash Shoulder widthndash Chest widthndash Hip widthndash Back of hip to back of kneendash Bottom of heel to back of kneendash Foot length
Wheelchair Frame Selection
ldquoProvide manual wheelchair users with a high-strength fully
customizable manual wheelchair made of the lightest possible
materialrdquo
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care
Professionals
Wheelchair Frame Selection
Lightweight Wheelchair (K0003) High-StrengthLightweight Wheelchair (K0004)
Recliner Wheelchair
Wheelchair Frame Selection
The Ultra Lightweight Wheelchair (K0005)
Ultra Lightweight Wheelchair ndashTitanium (K0009)
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The Mat Evaluation
bull Shouldersndash Roundedndash Internally rotated
bull Scapulaendash Abductionadductionndash Upwarddownward rotationndash Elevationdepressionndash Winging and tipping
bull Head Alignment ndash Forward headndash Rotationndash Lateral Flexion
The Mat Evaluation
bull Lower Extremity ROMndash Hip flexionndash Hip abductionndash Hip internalexternal rotationndash Knee flexionextensionndash Dorsiflexionplantar-flexion ndash Inversioneversion
bull Remember that you are examining ROM available for seated posture
The Mat Evaluation
The Mat Evaluation
bull Contractures ndash fixed vs flexiblebull Trunk stability and mobilitybull Hypertonicitybull Pain influenced by seated posturebull Muscle strength in relation to maneuvering
a wheelchair and changing position
The Mat Evaluation
bull Place the patient at the edge of the mat as close to 90-90-90 as possible
bull Measurementsndash Seat to top of headndash Seat to top of shouldersndash Seat to axillandash Seat to elbowndash Seat to inferior angle of scapulandash Head widthndash Shoulder widthndash Chest widthndash Hip widthndash Back of hip to back of kneendash Bottom of heel to back of kneendash Foot length
Wheelchair Frame Selection
ldquoProvide manual wheelchair users with a high-strength fully
customizable manual wheelchair made of the lightest possible
materialrdquo
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care
Professionals
Wheelchair Frame Selection
Lightweight Wheelchair (K0003) High-StrengthLightweight Wheelchair (K0004)
Recliner Wheelchair
Wheelchair Frame Selection
The Ultra Lightweight Wheelchair (K0005)
Ultra Lightweight Wheelchair ndashTitanium (K0009)
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The Mat Evaluation
bull Lower Extremity ROMndash Hip flexionndash Hip abductionndash Hip internalexternal rotationndash Knee flexionextensionndash Dorsiflexionplantar-flexion ndash Inversioneversion
bull Remember that you are examining ROM available for seated posture
The Mat Evaluation
The Mat Evaluation
bull Contractures ndash fixed vs flexiblebull Trunk stability and mobilitybull Hypertonicitybull Pain influenced by seated posturebull Muscle strength in relation to maneuvering
a wheelchair and changing position
The Mat Evaluation
bull Place the patient at the edge of the mat as close to 90-90-90 as possible
bull Measurementsndash Seat to top of headndash Seat to top of shouldersndash Seat to axillandash Seat to elbowndash Seat to inferior angle of scapulandash Head widthndash Shoulder widthndash Chest widthndash Hip widthndash Back of hip to back of kneendash Bottom of heel to back of kneendash Foot length
Wheelchair Frame Selection
ldquoProvide manual wheelchair users with a high-strength fully
customizable manual wheelchair made of the lightest possible
materialrdquo
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care
Professionals
Wheelchair Frame Selection
Lightweight Wheelchair (K0003) High-StrengthLightweight Wheelchair (K0004)
Recliner Wheelchair
Wheelchair Frame Selection
The Ultra Lightweight Wheelchair (K0005)
Ultra Lightweight Wheelchair ndashTitanium (K0009)
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The Mat Evaluation
The Mat Evaluation
bull Contractures ndash fixed vs flexiblebull Trunk stability and mobilitybull Hypertonicitybull Pain influenced by seated posturebull Muscle strength in relation to maneuvering
a wheelchair and changing position
The Mat Evaluation
bull Place the patient at the edge of the mat as close to 90-90-90 as possible
bull Measurementsndash Seat to top of headndash Seat to top of shouldersndash Seat to axillandash Seat to elbowndash Seat to inferior angle of scapulandash Head widthndash Shoulder widthndash Chest widthndash Hip widthndash Back of hip to back of kneendash Bottom of heel to back of kneendash Foot length
Wheelchair Frame Selection
ldquoProvide manual wheelchair users with a high-strength fully
customizable manual wheelchair made of the lightest possible
materialrdquo
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care
Professionals
Wheelchair Frame Selection
Lightweight Wheelchair (K0003) High-StrengthLightweight Wheelchair (K0004)
Recliner Wheelchair
Wheelchair Frame Selection
The Ultra Lightweight Wheelchair (K0005)
Ultra Lightweight Wheelchair ndashTitanium (K0009)
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The Mat Evaluation
bull Contractures ndash fixed vs flexiblebull Trunk stability and mobilitybull Hypertonicitybull Pain influenced by seated posturebull Muscle strength in relation to maneuvering
a wheelchair and changing position
The Mat Evaluation
bull Place the patient at the edge of the mat as close to 90-90-90 as possible
bull Measurementsndash Seat to top of headndash Seat to top of shouldersndash Seat to axillandash Seat to elbowndash Seat to inferior angle of scapulandash Head widthndash Shoulder widthndash Chest widthndash Hip widthndash Back of hip to back of kneendash Bottom of heel to back of kneendash Foot length
Wheelchair Frame Selection
ldquoProvide manual wheelchair users with a high-strength fully
customizable manual wheelchair made of the lightest possible
materialrdquo
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care
Professionals
Wheelchair Frame Selection
Lightweight Wheelchair (K0003) High-StrengthLightweight Wheelchair (K0004)
Recliner Wheelchair
Wheelchair Frame Selection
The Ultra Lightweight Wheelchair (K0005)
Ultra Lightweight Wheelchair ndashTitanium (K0009)
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The Mat Evaluation
bull Place the patient at the edge of the mat as close to 90-90-90 as possible
bull Measurementsndash Seat to top of headndash Seat to top of shouldersndash Seat to axillandash Seat to elbowndash Seat to inferior angle of scapulandash Head widthndash Shoulder widthndash Chest widthndash Hip widthndash Back of hip to back of kneendash Bottom of heel to back of kneendash Foot length
Wheelchair Frame Selection
ldquoProvide manual wheelchair users with a high-strength fully
customizable manual wheelchair made of the lightest possible
materialrdquo
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care
Professionals
Wheelchair Frame Selection
Lightweight Wheelchair (K0003) High-StrengthLightweight Wheelchair (K0004)
Recliner Wheelchair
Wheelchair Frame Selection
The Ultra Lightweight Wheelchair (K0005)
Ultra Lightweight Wheelchair ndashTitanium (K0009)
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Wheelchair Frame Selection
ldquoProvide manual wheelchair users with a high-strength fully
customizable manual wheelchair made of the lightest possible
materialrdquo
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care
Professionals
Wheelchair Frame Selection
Lightweight Wheelchair (K0003) High-StrengthLightweight Wheelchair (K0004)
Recliner Wheelchair
Wheelchair Frame Selection
The Ultra Lightweight Wheelchair (K0005)
Ultra Lightweight Wheelchair ndashTitanium (K0009)
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Wheelchair Frame Selection
Lightweight Wheelchair (K0003) High-StrengthLightweight Wheelchair (K0004)
Recliner Wheelchair
Wheelchair Frame Selection
The Ultra Lightweight Wheelchair (K0005)
Ultra Lightweight Wheelchair ndashTitanium (K0009)
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Wheelchair Frame Selection
The Ultra Lightweight Wheelchair (K0005)
Ultra Lightweight Wheelchair ndashTitanium (K0009)
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Wheelchair Frame Selection
bull Aluminum vs Titaniumndash Weightndash Durabilityndash Flexibility of Materialndash Aesthetics
bull Folding Frame vs Rigid Framendash Weightndash Durabilityndash Ease of loadingunloadingndash Foot propulsion vs upper extremity only
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The Cushion
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The Cushion
bull Consider ndash Positioningndash Maintenancendash Impact on functional performancendash Comfortndash Pressure distribution
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Pressure Mapping
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Pressure Mapping
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Pressure Mapping
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Pressure Mapping
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The Foot Support
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The Foot Support
bull Consider impact onhellipndash Position of the pelvisndash Functionndash Spasticityndash Skin and joint protection
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The Backrest
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The Backrest
bull Select a backrest thatndash Aligns the spine in a neutral positionndash Supports the trunk in midlinendash Allows room for the pelvisndash Allows the arms to be moved behind the trunk
easilyndash Promotes an upright stable and functional
position
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The Backrest
Tension Adjustable Back Upholstery Custom Solid Backrest
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The Backrest
bull Other factors to considerndash Ease of managing backrest hardwarendash Durabilityndash Weightndash Comfortndash Adjustability
bull Heightbull ForwardRearwardbull Angle
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The Armrests
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The Armrests
Using our arms to stabilize ourselves is something we all do
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The Armrests
bull Consider impact onndash Performance functional tasksndash Posturendash Pressure distribution
bull Excluding the armrests can sometimes promote a more functional active position
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Wheelchair Accessories
bull Tiresndash Pneumatic tiresndash Pneumatic tires with flat free insertsndash Solid tires
bull Castersndash Larger casters increase rolling resistancendash Smaller casters decrease ease of negotiating
cracks bumps and thresholds
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Wheelchair Accessories
bull Push-rimsndash Standard aluminum anodizedndash Friction-coatedndash Ergonomic options
bull Push Handlesndash Integratedndash Bolt-on
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Wheelchair Accessories
bull Armrestsndash Tubular swing-away armrestsndash T-style armrestsndash Flip-back armrests
bull Clothing Guardsndash Removablendash Integratedndash Fold-down or flip-back
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Wheelchair Accessories
bull Heel Loops and Calf Strapsndash Keep feet positioned on the footplate
bull Anti-tippersndash Prevent wheelchair from tipping backward
bull Seat Beltndash Padded or non-paddedndash Push button or lever style
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Wheelchair Configuration
bull Dimensionsndash Seat Widthndash Seat Depthndash Seat to Back Anglendash Back Height
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Wheelchair Configuration
bull Other Adjustmentsndash Camberndash Rear Wheel Spacingndash Seat to Footrest ndash Front and Rear Seat to Floor Heightndash Center of Gravity
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Wheelchair Configuration
To achieve ideal seat height the elbow
angle should be 100 to 120 degrees when the hand is placed at the top dead-center
of the wheel
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Wheelchair Configuration
Most often when the seat height is adjusted
appropriately the finger tips should be at same level as the axle when the arms are hanging
down to the sides
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Wheelchair Configuration
Lower seat position improves propulsion biomechanicshellip
BUTIf the seat is too low the user is forced to
push with arms abducted and shoulders elevated
Impingement Syndrome anyone
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Wheelchair Configuration
The wheelchair is NOT a coat rack
Adding weight can affect stability
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Time To Put Your Thinking Caps On
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Case Study
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Case Study
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Case Study
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Case Study
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Case Study
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Case Study
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Manual Wheelchair Seating and Mobility
Preserving the Upper Limb and Promoting Function Throughout the Lifespan
Kristen Fiola PT DPT
Zachary Staats OTR
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Whorsquos ready for ROUND TWO
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Objectives
bull Describe principles of strengthening related to upper limb preservation
bull Identify wheelchair push stroke mechanics and related risks for the development of upper extremity overuse injuries
bull Identify proper technique and body mechanics for performance of advanced wheelchair skills
bull Discuss clinically feasible methods for the objective assessment of manual wheelchair propulsion
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
ICF Model Health Condition
bull Overuse injuries are common in wrist elbow and shoulder
bull Shoulderndash Shoulder problems are common in both tetraplegia
and paraplegia (between 30 and 60)ndash Higher percentages in people with tetraplegia
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
ICF Model
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
ICF Model Health Condition
bull Common shoulder conditions include ndash Impingement syndrome ndash Capsulitisndash Osteoarthritisndash Recurrent dislocations ndash Rotator cuff tearsndash Bicipital tendinitisndash Myofacial pain syndrome involving cervical
and thoracic paraspinals
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Body Systems
bull Any disruption of the dynamic stabalizers will alter the center of rotation of the humeral head resulting in excessive excursion of the humeral head in the glenoid fossandash Decreased sub-acromial space due to osseous
changes muscular andor capsular tightnesslaxityndash Altered innervationndash Disruption of force couples (eg rotator cuff muscles
depress humeral head and offset deltoids and supraspinatus)
bull Worsened by inflammation fibrosis of tendonsbursae
Nawoczenski et al 2009
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Body Systems
People with Tetraplegiandash High joint reaction forces with pushrim contactndash Increased demand on muscles that depress the
humeral headndash Decreased strength
innervation of rotator cuff muscles
Mulroy et al 2004
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Activity
bull Increased daily weight bearing demands on shoulder during ndash Transfersndash Weight shiftsndash Self-careADLs ndash Wheelchair propulsion
bull Often results in pain less than1 year post injury (Requejo et al 2008)
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Activity
bull Shoulder joint reaction forces during level wheelchair propulsion (Mulroy et al 2004)
ndash Low to Moderate (8-46N) ndash Average muscle response low to moderate (14-
35 max voluntary contraction)
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Activity
Repetitive Nature
darrMuscle Fatigue
darrImpingement Musculotendinous injury
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Participation
bull Pain only factor correlated with lower quality of life scores (Lundqvist et al 1991)
bull Individuals with UE pain (Dalyan et all 1999)
bull 26 needed help with functional activities bull 28 reported limited independence
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Participation
Individuals with UE pain bull Higher rate of unemployment
ndash 214 vs 71 bull Rate of full-time employment lower
ndash 20 vs 452
(Dalyan et al 1999)
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Participation Sports
bull Wheelchair athletes increased load and repetitive stress
bull Fast propulsion greater forces in shoulder than free propulsion ndash Increased number of
push strokesmin (wheelchair basketball racing etc) Mulroy et al 2004
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Participation Sports
Conversely increased strength and endurance of athletes may have protective effect on the
shoulder (Mulroy et al 2004)
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
How Can We Help
bull Strengthening and stretching programbull Educationbull Assess past medical and social history
ndash Job and leisure requirementsbull Body habitusbull Wheelchair configuration
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Stretch the Fronthellip
bull Upper Trapbull Pectoralis (chest)bull Long head of bicepsbull Posterior shoulder
capsule
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
hellipand Strengthen the Back
bull Rotator CuffScapularndash Middle amp Lower Trapsndash Serratus Anteriorndash External Rotators
bull Shouler and Elbowndash Shoulder Extensorsndash Elbow Extensorsndash Elbow Flexors
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Education
bull Educating client on shoulder preservationndash ADLndash Mobility
bull Transfersbull Push stroke mechanics
ndash Personalize recommendations specific to the individual
bull Past medical historybull What are their participation level goals
bull Get them to buy inndash Show them the literature
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
How Should You Propel
bull Canrsquot avoid the excessive demands on shoulder
bull Can implement techniques to decrease forces through the upper extremities
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Pushing a Wheelchair
bull 4 identified push techniquesndash Single loop overndash Double loop overndash Archingndash Semi-circular
bull Most common single loop overbull Most efficient semi-circular
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Propulsion Technique
Single Loop-Over Double Loop-Over
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Propulsion Technique
Arching Semi-Circular
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Propulsion Technique
bull Educate the patient to use long smooth strokes that limit high impacts on the pushrim
bull Educate the patient to allow that hand to drift down naturally keeping it below the pushrim when not in actual contact with that part of the wheelchair
Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-care Professionals
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Propulsion Technique
bull Semi-circular pattern is associated withndash Lower stroke frequencyndash Greater time spent in the push phasendash Less angular joint velocity and acceleration
bull Semi-circular pattern decreases abrupt changes in direction and extra hand movements
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Propulsion Technique
bull Recommendationsndash Use the semi-circular patternndash Ride it out optimize each pushndash Avoid friction of hands on the wheelsndash Evaluate wheelchair configuration check out
the shoulder and elbow position
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Pushing a Wheelchair
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Wheelchair Configuration
A quick review from Part Onehellip
Seat height and position of rear axle are key to creating an efficient push stroke
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Wheelchair Configuration
bull Lower seat position improves propulsion biomechanicsndash Greater upper limb motionsndash Greater contact anglendash Lower frequencyndash Higher mechanical efficiency
bull However if the seat is too low the user is forced to push with arms abducted and shoulders elevated
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Wheelchair Configuration
bull Adjust the rear axle as far forward as possible without compromising the stability of the userndash Decreases rolling resistancendash Increases contact anglendash Less muscle effortndash Lower push frequencyndash Smoother joint excursions
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Propulsion Training
bull Frequency of propulsionndash Approximately 1 push per secondndash Decreased frequency = decreased demands
on the shoulder jointbull Contact Angle
ndash Approximately 100 degrees from pushrim contact to pushrim release
bull Velocityndash 106 ms to safely cross an intersectionndash 136 ms is average walking speed
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The SmartWheel
bull The SmartWheel is a clinical assessment tool used to objectively measurendash Velocityndash Force exerted on the pushrimndash Push frequencyndash Push angle
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The SmartWheel
bull The SmartWheel can be used forndash Propulsion Trainingndash Equipment Selectionndash Equipment Justificationndash Equipment Set-upndash Comparison to National Database
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
No SmartWheel No Problem
bull So what if my clinic doesnrsquot have a SmartWheelndash Set up a straight path and measure distancendash Instruct patient to start propelling when heshe is
ready Begin stop watch as soon as hands contact the pushrim
ndash Count the number of push strokes during the trialndash Stop the stop watch when the patient crosses the
finish linendash Velocity is distancetimendash Push frequency is number of pushestime
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
No SmartWheel No Problem
bull Be sure to observe the patientrsquos propulsion style and provide education as needed Information can be used tondash Objectively document propulsion stylendash Compare wheelchair framesndash Determine wheelchair set upndash Train patients on proper propulsion technique
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Advanced Wheelchair Skills
bull Not for everyonebull Considerations
ndash Agendash Personalityndash Body Habitusndash Coordinationndash Strengthndash Flexibility
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Who is appropriate for advanced level skills
bull Hand function ndash Assists in the maneuverability of the
wheelchairndash Some patients with tetraplegia are able to
perform advanced wheelchair skills ndash slower to progress
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Who is appropriate for advanced level skills
bull Abdominalsndash Assist with trunk balancendash The lower the level of paralysis the easier the
skills should be
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Reminder
Practice in the clinic is important BUT
mastery can only be achieved with practice outside in the community
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Rememberhellip
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Where do we start
bull Static wheeliesbull Learn the balance pointbull Assess center of gravity
ndash Too tippy Need to adjust rear axle
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Static Wheelies
bull Training progressionndash Place patient into the wheelie
positionndash Find the balance pointndash Maintain the balance point
bull Teach the patient to assume the wheelie positionndash Quick forward stroke to pop-
up the casters
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Dynamic Wheelies
bull Forwardbull Backwardbull Turnscircles
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
And nowhellipApply what you have learned
bull It is usually easier to negotiate rough terrain in a wheelie position
bull Need to perform dynamic wheelies for most advanced skillsndash Rampsndash Curbsndash Stairsndash Escalators
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Ramps Going Up
bull Lean forward into the slope of the ramp
bull Steeper slopendash Shorter simultaneous
strokes ndash Move hands rapidly
between pushes
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Ramps Going Down
bull Control the wheelchair by the resistance of your hands on the pushrims
bull Lean trunk backward into the slope of the ramp
bull May use zig-zag motion to slow momentum
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Curbs Going Up
bull Static startndash Lower curbs
bull Dynamic startndash Hints
bull Momentumbull Timing bull Technique
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Curbs Going Down
bull Backwardndash Lean forward and
control the back tires to the ground
ndash Back off in a wheelie bull Forward
ndash Transition to wheeliendash Maintain the wheelie
until on the lower surface
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Stairs Going Up
bull Forward or Backwardndash With 1 railing and a
hand on 1 tirendash With 2 railings
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Stairs Going Down
bull Backward ndash One or two railings
bull Forwardndash Controlled wheelie
bull Easiest when a large horizontal surface and small vertical rise
bull Easiest when small series of steps rather than a long flight of stairs
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Escalators Going Up
bull Roll forward and place the front casters on the step
bull Grab the handrails and allow the motion to take you up
bull Remember at the top to push off so that the casters do not get stuck
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Escalators Going Down
bull Descend backwardndash Grab the handrailsndash Lean forward and
allow the motion to take you down
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Hill Up and Down
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The ldquoTake-Homerdquo
bull Assess your client thoroughlybull Choose the appropriate frame and
accessoriesbull Consider configurationbull Provide a thorough exercise programbull Educate on the correct propulsion
techniquebull Teach skills for success in all
environments
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
The ldquoTake-Homerdquo
Regardless of our specific disciplines we all play valuable roles in ensuring the needs of
the client are thoroughly met
Together we can all help to preserve upper limb function and promote functional
performance throughout the lifespan of individuals with spinal cord injury
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Questions
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Special Thanks Tohellip
Steven FoxSunrise Medical
Jodi SmigelskiMSL Associates Inc
Thana FranceBrowningrsquos Pharmacy and Healthcare
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Special Thanks Tohellip
Our ldquoModelsrdquo (in order of appearance)
Linda Norah DavisRyan LambertDamian Maya
Charles RumeryEmily Potter OTR MOT
Eric Lantz OTR
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
Obtaining CME Credit
If you would like to obtain CME credit for this activity please visit
httpwwwpesgcecomPVAsummit2011
This information can also be found in the Summit 2011 Program on page 8
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
References
Boninger ML RA Cooper MA Baldwin SD Shimada and A Koontz Wheelchair pushrim biomechanics and axle position Archives of Physical Medicine and Rehabilitation 81 (2000) 608-13
Boninger ML AL Souza RA Cooper SG Fitzgerald AM Koontz and BT Fay Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion Archives of Physical Medicine and Rehabilitation 82 (2002) 718-23
Cowan R E Boninger M L Sawatzky B J Mazoyer B D amp Cooper R A (2008) Preliminary Outcomes of the SmartWheel Usersrsquo Group Database A Proposed Framework for Clinicians to Objectively Evaluate Manual Wheelchair Propulsion Achives of Physical Medicine and Rehabilitation 89 260-268
Consortium for Spinal Cord Medicine Preservation of Upper Limb Function Following Spinal Cord Injury A Clinical Practice Guideline for Health-Care Professionals Washington DC Paralyzed Veterans of America April 2005 The Journal of Spinal Cord Medicine2005 28(5)434-470
Dalyan M Cardenas Gerard Upper Extremity Pain After Spinal Cord Injury Spinal Cord 1999 37191-196
Eng J Teasell Miller et al Spinal Cord Injury Rehabilitation Evidence Method of the SCIRE Systematic Review Topics in Spinal Cord Injuries2007 13(1) 1-10
Gironda R Clark M Neugaard B et al Upper Limb Pain in a National Sample of Veterans with Paraplegia Journal of Spinal Cord Med 2004 27 120-127
Lundqvist C Siosteen Blomstrand et al Spinial Cord Injuries Clinical Functional and Emotional Status Spine 1991 16(1)78-83
Hoxie RE Rubenstein LZ (1994) Are older pedestrians allowed enough time to cross intersections safely Journal of the American Geriatric Society 42 241-4
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
References
Mulroy S Farrokhi Newsam et al Effects of Spinal Cord Injury Level on the Activity of Shoulder Muscles During Wheelchair Propulsion An Electromyographic Study Arch Phys Med Rehabil 2004 85 925-934
Nawoczenski A Ritter-Soronen Wilson et al Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury Physical Therapy 2006 86(12)1604-1618
Nichols P Norman Ennis Wheelchair Userrsquos Shoulder Shoulder pain in patients with spinal cord lesions Scand J Rehab Med 1979 11 29-32
Requejo P Mulroy Haubert et al Evidence-Based Strategies to Preserve Shoulder Function in Manual Wheelchair Users with Spinal Cord InjuryTop Spinal Cord Injury Rehabilitation 2008 13(4) 86-119
Robinett CS amp Vondran MA (1988) Functional ambulation velocity and distance requirements in rural and urban communities A clinical report Phys Ther 68 1371-3
Shimada S D Robertson R N Bonninger M L amp Cooper R A (1998) Kinematic characterization of wheelchair propulsionJournal of Rehabilitation Research 35(2) 210-218
Sie IH Waters Adkins et al Upper Extremity pain in the Post Rehabilitation Spinal Cord Injured Patient Arch Phys Med Rehabil1992 7344-48
The SmartWheel Available at httpwww3riverscomswusergroup20pagephp Accessed July 1 2009
Van der Woude LHV DJ Veeger RH Rozendal and TJ Sargeant Seat height in handrim wheelchair propulsion Journal of Rehabilitation Research amp Development 26 (1989) 31-50
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Disclosures
- Meet Your Presenters
- Objectives
- You Got This One
- Interdisciplinary Approach
- Whatrsquos the Big Deal
- ANDhellip
- The Journey Beginshellip
- Seating and Positioning
- How Should One Sit
- How Should One Sit
- Client Interview
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- The Mat Evaluation
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- Wheelchair Frame Selection
- The Cushion
- The Cushion
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- Pressure Mapping
- The Foot Support
- The Foot Support
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Backrest
- The Armrests
- The Armrests
- The Armrests
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Accessories
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Time To Put Your Thinking Caps On
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Case Study
- Manual Wheelchair Seating and MobilityPreserving the Upper Limb and Promoting Function Throughout the Lifespan
- Whorsquos ready for ROUND TWO
- Objectives
- ICF Model Health Condition
- ICF Model
- ICF Model Health Condition
- Body Systems
- Body Systems
- Activity
- Activity
- Activity
- Participation
- Participation
- Participation Sports
- Participation Sports
- How Can We Help
- Stretch the Fronthellip
- hellipand Strengthen the Back
- Education
- How Should You Propel
- Pushing a Wheelchair
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Propulsion Technique
- Pushing a Wheelchair
- Wheelchair Configuration
- Wheelchair Configuration
- Wheelchair Configuration
- Propulsion Training
- The SmartWheel
- The SmartWheel
- No SmartWheel No Problem
- No SmartWheel No Problem
- Advanced Wheelchair Skills
- Who is appropriate for advanced level skills
- Who is appropriate for advanced level skills
- Reminder
- Rememberhellip
- Where do we start
- Static Wheelies
- Dynamic Wheelies
- And nowhellipApply what you have learned
- Ramps Going Up
- Ramps Going Down
- Curbs Going Up
- Curbs Going Down
- Stairs Going Up
- Stairs Going Down
- Escalators Going Up
- Escalators Going Down
- Hill Up and Down
- The ldquoTake-Homerdquo
- The ldquoTake-Homerdquo
- Questions
- Special Thanks Tohellip
- Special Thanks Tohellip
- Obtaining CME Credit
- References
- References
- Slide Number 121
-