Use it or Lose it?

A Look at Shoulder Pain and Shoulder Preservation in Manual Wheelchair Users

Presented by:

Jill Alm

Use it or Lose it?

• As we age– Aerobic activity (VO2 max), maximum heart

rate, flexibility and muscle strength is all decreasing.

– Our body fat is increasing.

• Our own experiences with sickness/injury.

The Good News

• We are all trainable.

• Can be reversed.

What about Wheelchair Mobility?

• Exercise has shown to reduce shoulder pain and improved function.

• Wheelchair athletes vs. non-athletes.

• Shoulder Pain in adult vs. child onset wheelchair users.

www.nextstepfitness.org

Pushing-boundaries.orgRedmond, WA

www.mindbodysolutions.org

mo·bil·i·ty  noun 1. The quality or state of being in motion.

freedom, noun 1. the state of being free or at

liberty rather than in confinement or under physical restraint

Freedom = Mobility

Shoulder Pain and Mobility

Goals • Examine the prevalence and

effects of shoulder pain in MWC users.

• Learn about wheeled technology available to decrease shoulder pain.

Prevalence of Shoulder Pain in MWC users

Up to 80% of Manual Wheelchair Users suffer from shoulder pain.

• Chronic UE pain is the most frequently identified medical concern and interferes with work, home, social and recreational activities.

• Using the WUSPI, the highest intensity of pain is: – Pushing up an incline– Pushing for longer than 10 minutes– While sleeping

Possible Correlations to Shoulder Pathologies

– Time since injury– Repetitive nature of wc propulsion– Strength of shoulder muscles– Loading of joints at extremes of motion– Muscular weakness or imbalance– Transfers

Anatomy of the Shoulder

• Most movable joint in the body.• Unstable joint due to the ROM.• Subject to injury because the

ball is larger than the socket that holds it.

• To maintain stability, it must be anchored by its muscles, tendons,

and ligaments.

To Add to the Shoulder Pain…

• Increases with age. • Can lead to activity limitations.• Lowers subjective quality of life and

physical activity scores.• Even a relatively benign ramp (2.9

degrees) places a large demand on the musculature of the UE.

Conclusions

• Strategies should be developed.

• Need to develop programs of prevention, patient education, diagnosis and treatment.

• Attention to and interventions

for shoulder pain may improve their overall quality of life and physical activity.

• Shoulder pain is a multidimensional process.

Spinning our Wheels? • Published in 2005• Consolidates

research findings and relates them directly to clinical practice.

• www.pva.org

Wheeled Technology

Geared Wheels General Application

– MAGICWHEELS 2-Gear Wheels Specialty Application– Renegade Wheelchairs (Multi-gear lever

drive system)– Mountain Trike, UK (3 Wheel with lever

drive system)

Wheeled Technology

Power Assist – E-motion– Xtender– Tail Wind– Zinger

Other– Wijit (Lever Drive System with added speed)

• Compatible with any manual wheelchair

• 24” and 25” wheels• Quick release• Handrim and tire

choices available• No batteries or

motors

• The gears add 5 lbs per wheel• No added width • Up to 6 degrees of camber available• Standard wheels are interchangeable• Fully RESNA tested and 5 year warranty• MSRP: $4995.00• HCPCS code: E2227

• 1:1 gear for standard use• 2:1 Low gear (think bicycle

gears)– Easy gear shifting– Climb hills/ramps with

50% less effort– Automatic hill holder– Increased downhill control– Other uses of the low gear

Users

• Shoulder pain• Mobility/independence is important!• In a chair for 15-30+ years• Can push on a flat surface• Experiencing a change in lifestyle

– Van ramp – Experiencing difficulty with current mobility– Change in health – Going to college

• Self reliant

Effect of 2-Speed Geared Manual Wheelchair Propulsion (MAGICWHEELS) on Shoulder Pain

and Function

Archives of Physical Medicine and Rehabilitation Volume 88, p. 1622 – 1627, December 2007

Margaret A. Finley, PhD, PTMary M. Rogers, PhD, PT

University of Maryland School of MedicineDepartment of Physical Therapyand Rehabilitation Sciences

• OBJECTIVE: To investigate the impact of a manual 2-gear wheelchair wheel (MAGICWHEELS) on shoulder pain and function in manual wheelchair users.

• DESIGN: A single-group, repeated-measures pre- and post- design with baseline and retention.

• SETTING: General community.

• PARTICIPANTS: Full time manual wheelchair users currently experiencing shoulder pain.

Methods 17 MWCU with shoulder pain (WUSPI score >10)

Age: 46.014.0 years

Duration WC use: 15.110.1 years

Gender: Male=9 ; Female =8

Disabilities: Spina bifida(1) ;SCI (11); post-polio(1);stroke (1);ataxia (1);Rheumatoid arthritis(1);spinal stenosis(1)

• Phase I (baseline): one month using own wheelchair and wheels

• Phase II (MAGICWHEELS): five months with the 2-speed MAGICWHEELS attached to own wheelchair

• Phase III (retention): one month in own wheelchair and wheels

Protocol

• transfer from bed to wheelchair

• transfer from wheelchair to car

• transfer from wheelchair to tub or shower

• loading the wheelchair into a car

• pushing the wheelchair for 10 minutes or more

• pushing up ramps or outdoor inclines

• lifting objects to remove them from an overhead shelf

• putting on pants

• putting on a T-shirt or pullover

• putting on a button down shirt

• washing one’s back

• usual daily activities at work or school

• driving

• performing household chores

• sleeping

MAIN OUTCOME MEASURES: Wheelchair Users Shoulder Pain Index

(WUSPI)

Percentage Change in WUSPI Score

0

20

40

60

80

100

120

baseline (n=17)

wk 1 (n=17)

wk 2* (n=17)

wk 3* (n=17)

wk 4* (n=17)

wk 8 * (n=16)

wk 12* (n=16)

wk 16* (n=14)

wk 20* (n=12)

Week in Protocol

Per

cen

tag

e o

f B

asel

ine

WU

SP

I Sco

re

* = significant change from baseline

WUSPI items Showing Significant Reduction

• ten minute push• ramp ascent• driving • chores• sleeping

Conclusions

• MAGICWHEELS 2-gear wheels has been shown to reduce shoulder pain with short time use (2 weeks) indicating a rapid response to the intervention.

• A progressive reduction in pain continued throughout 20 week study.

• These findings indicate the potential (p=0.015) for shoulder pain reduction with the use of MAGICWHEELS during mobility, even in highly functional manual wheelchair users.

…before the study we considered the possibility that the added weight (~ 10lbs) of the MAGICWHEELS would lead to an increase in shoulder pain.

Weight

The concerns proved UNFOUNDED as the individual item analysis on the WUSPI revealed that there was no increase in pain on the weight-dependent item, “loading wheelchair into car,” as reported by the 9 participants who regularly performed the task, and overall shoulder pain was reduced significantly.

Weight

Weight

ADP testing by the Ontario Government.Patricia O’Neill, M.Sc.E, P.Eng., Research

Engineer

• The Ottawa Hospital Rehabilitation Centre• RESNA Testing, Rolling Resistance. Force

to maintain rolling.•Regular wheels = 10.3 N•MW = 8.5 N (18% reduction)

Effects of Geared Wheels on Shoulder Muscle Activity (EMG) During Wheelchair Ramp Ascent

and Descent

Department of Kinesiology, University of Waterloo, Waterloo, Ontario, CanadaLynne Pronovost, Sam Howarth, Clark Dickerson, Jan Miller-Polgar, Jack Callaghan.

• The study could not differentiate between MW in 1:1 and standard wheels pushing up a ramp.

• Showed the measured muscle activation when propelling MAGICWHEELS in low gear up a 5 degree incline is less than 50% of maximal voluntary contraction.

• This is below levels known from other studies to cause muscle damage in repetitive situations like pushing a wheelchair.

Effects of Geared Wheels on Shoulder Muscle Activity (EMG) During Wheelchair Ramp

Ascent and Descent

ConclusionIt appears geared wheels may prolong time to fatigue and decrease risk of injury for MWC users.

Submitted to Archives of Physical Medicine and Rehabilitation, Clinical Biomechanics, and ISS 2010.

Pushrim Activated Power Assist Wheels (PAPAW)

E-motion Drive Wheel M15• 22” or 24” wheels• Quick Release• Wheelchair Compatibility chart reference

Easy, Moderate, Difficult to install • Motor integrated into the wheel hub • Widens the wheelchair by 1-1.5”

depending on the model • Handrims: Stainless steel, removable

rubber covers, vinyl coated.

E-motion Drive Wheel M15

Weight• 2 wheels: 50 lbs

2 batteries: 10 lbs• 1 charger: 4 lbs.

Battery Pack• Up to 16 miles range per charge • Lithium-Ion technology, optional spare

batteries available• Charging time: 6 hours

E-motion Drive Wheel M15

Ergonomic Control System (ECS)• Rollback delay

– Activation via ECS – Prevents wheelchair from rolling back while climbing

inclines or ramps• ECS Features

– Programming of driving parameters (10 parameters in all)

– On/Off, assistance levels, info button for current status display

• Two assistance levels – High/Low, individually programmable

• Remote Battery Monitor – Check battery capacity from the upright sitting

position• Self-diagnosis

– Display of service and diagnostic codes via LCD screen on the ECS

• Coded Radio Transmission – Prevents interferences with other electrical devices

E-motion Drive Wheel M15

WarrantyLimited 24-month period - excluding accessories and batteries. After the initial 12-month warranty period, problems are dealt with on a case by case basis.

Price: MSRP $7295Extra battery Packs, Set of 2 Li-Ion: $1495

Code: E0986

Quickie Xtender

• 24” Wheels• 18” seat to floor height required• Quad release axle, quick disconnect• Automatic wheel synchronization system which

compensates for any arm strength imbalance the user may have.

• Available in two versions– Increases the force by a factor of 1.5. – Increases the force applied by a factor of 3.

• The motor also acts as a break when traveling downhill.

• Total additional weight is 37 lbs.

Quickie Xtender

Compatibility• Available on the Quickie 2, 2HP, GP/GPV, GP

Swing Away, GP, GT, GTX, and Titanium chair models.

• Redesigned axle-plate allows the chair's width to stay constant when converting to a power-assist platform.

Battery A single battery weighing 6 1/4 lbs.

• Battery has its own charger • Takes 2 - 3 hours to charge.• Range 9.5 miles

Quickie Xtender

Warranty: 2 year

MSRP: $6,295.00

Extra battery: MSRP $1200Extra Charger: MSRP $850

Code: E0986

Power Assist Users

• Shoulder pain• Difficulty pushing on flat surface• Distanced pushed during the day may be a

factor• Home environment may not accommodate

PWC• Willing to accept a power solution

Power-Assisted Wheels Ease Energy Costs and Perceptual Responses to Wheelchair Propulsion in Persons With Shoulder Pain

and SCI

Archives of Physical Medicine and Rehabilitation Vol. 89, p. 2080-2085, November 2008.

Mark S. Nash, PhD, Daan Koppens, MD, Miriam van Haaren, MD, Andrew L. Sherman, MD, James P. Lippiatte, John E. Lewis, PhD.

Department of Neurological Surgery, Miller School of Medicine, University of Miami, Miami, FL

ProtocolOBJECTIVE: Test effects of pushrim-activated

power-assisted wheelchairs (PAPAWs) on the energetics and perceptual responses to steady-state and intensity-graded wheelchair propulsion in persons with paraplegia and tetraplegia having chronic shoulder pain.

DESIGN: Test, retest with a control condition.

SETTING: Academic medical center.

Methods

• PARTICIPANTS: Subjects (N=18) aged 19 to 70 years with chronic, motor-complete paraplegia and tetraplegia having confirmed shoulder pain.

• INTERVENTIONS: Study participants underwent testing on 4 randomized nonconsecutive days during either – 6 minutes of steady-state or – 12 minutes of intensity-graded wheelchair propulsion on

stationary rollers. – Participants used their own manual wheelchair and either

their customary wheels or power-assist wheels attached with an axle bracket.

Main Outcome Measures

• Oxygen consumption (V(.)O2, L/min)• Distance (m)• Energy cost (L/m)• Ratings of perceived exertion (RPE; Borg

Categorical 6-20 Scale) were measured during propulsion.

Results

Significant main effects of testing were observed for oxygen consumption, heart rate, and RPE in both subject groups.

Distances propelled were significantly increased in both groups across both tests and in each of their exercise stages.

Conclusions

Use of PAPAWs by persons with paraplegia and tetraplegia having shoulder pain significantly lowers energy cost responses and perceived exertion compared with manual wheelchair propulsion while significantly increasing the distanced propelled.

Emotion Video

Video

A Preliminary Study on the Impact of Pushrim-Activated Power-Assist Wheelchairs

Among Individuals with Tetraplegia

Archives of Physical Medicine and Rehabilitation Volumte 87, p. 821-829, October 2008.

Nash MS, Koppens, D, van Haaren M, Sherman AL, Lippiatt JP, Lewis JE.

Department of Rehabilitation ScienceUniversity of Pittsburgh

Objectives

This preliminary study was to evaluate the impact of pushrim- activated power-assist wheelchairs (PAPAWs) on mobility, community participation, satisfaction, and psychosocial impact among

individuals with tetraplegia.

Design

• 15 manual wheelchair users with tetraplegia completed a 4-wk protocol

• 2-wk trial using their personal wheelchairs for mobility and a 2-wk trial where they were provided with a PAPAW and could choose either wheelchair for mobility.

Methods

• Mobility levels with both wheelchairs were recorded.

• Participants completed daily questionnaires regarding community participation and their satisfaction with the wheelchair used.

• The Psychosocial Impact of Assistive Devices Scale was used to compare the psychosocial impact of PAPAWs with their personal wheelchairs.

Results

• Participants chose to use PAPAWs and their personal wheelchairs at a similar frequency in the PAPAW trial.

• The distances traveled with both wheelchairs were not statistically different (P = 0.09).

• Participants traveled significantly faster with PAPAWs (P = 0.03).

• PAPAWs did not result in significantly greater community participation, satisfaction, and psychosocial impacts than the personal wheelchairs.

Conclusions

PAPAWs could be a viable mobility option for individuals with tetraplegia, which can provide independent mobility especially for outdoor activities.

A user's preference, life style, physical conditions, transportation issues, and environmental factors should be considered in prescribing such a device.

Considerations

• Physical condition• Functional abilities• Psychological factors• Environmental issues: Home, community

and work environment• Transportation• Personal preference• Technology

World Heath OrganizationSedentary lifestyle: A Global Public Health

Problem

• A major underlying cause of death, disease, and disability.

• Physical inactivity accounts for approximately 2 million deaths every year.

• One of the 10 leading causes of death and disability in the world.

• Physical inactivity increases all causes of mortality, doubles the risk of cardiovascular disease, type II diabetes, and obesity.

• Increases the risks of colon and breast cancer, high blood pressure, lipid disorders, osteoporosis, depression, and anxiety.

Review

 

Can push on flat

surfacesShoulder

pain

Value physical activity/ Want to stay in MWC

Less value in physical

activity/Accept power

Smaller footpri

nt

Manual Wheelchair x ? x o  x

MAGICWHEELS x x x o  x

Power Assist o x o  x x

Power Wheelchair o  x  o x o 

Use it or Lose it

• Match technology to the user• Educate on relative benefits of

the technology available– Physical activity– Psychological freedom/mobility– Smallest footprint– Maintenance/reliability– Long term costs

Questions?

Jill Alm

jill@magicwheels.com

206-282-0760 x804