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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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