Effort in Newton For A Propulsion

Evidence-Based Strategies to Preserve
Shoulder Function in Manual

Wheelchair Users with Spinal Cord
Injury
Philip S. Requejo, Sara J. Mulroy, Lisa Lighthall Haubert, Craig J. Newsam,
JoAnne K. Gronley, and Jacquelin Perry
The increased demand on the upper limbs during manual wheelchair use results in a high prevalence of
shoulder pathology in people with spinal cord injury (SCI). Because individuals with SCI are dependent on
their upper extremities for mobility and daily activities, shoulder dysfunction can present a devastating loss
of independence and decreased quality of life. Research on quantification of shoulder loading and muscular
demands during wheelchair propulsion, self-transfers, weight-relief raises, and overhead activities is
presented. This review examines evidence-based recommendations aimed at preserving shoulder function
by addressing environmental factors related to ergonomics, equipment selection, and performance
technique and personal factors related to enhancement of the load-bearing capacity of shoulder structure
through strengthening and resistance training. Key words: exercise, joint loading, muscular demands
electromyography, pain, paraplegia, shoulder, spinal cord injury, tetraplegia, wheelchair
he increased demand on the upper

limbs required for daily function in
people with spinal cord injury (SCI)
who use a manual wheelchair results in a high
prevalence of shoulder pain and injury. Preservation of shoulder function after SCI is important for maintaining mobility and community
participation. This article will address strategies designed to reduce shoulder joint loading
and muscular demands and to increase the

shoulders capacity to handle the loads during
manual wheelchair activities in persons with
paraplegia and tetraplegia from SCI.
Philip S. Requejo, PhD, is Research Engineer,

Pathokinesiology Laboratory and Rehabilitation Engineering Program, Rancho Los Amigos National Rehabilitation Center, Downey, California.
Amigos National Rehabilitation Center, Downey,

California.
Sara J. Mulroy, PhD, PT, is Director, Pathokinesiology Laboratory, Rancho Los Amigos National Rehabilitation Center, Downey, California.
Lisa Lighthall Haubert, MPT, is Research Physical
Therapist, Pathokinesiology Laboratory, Rancho Los
California.
Craig J. Newsam, DPT, was Research Physical
Therapist, Pathokinesiology Laboratory, Rancho Los
86
SCI Demographics
Approximately 11,000 new survivors of
SCI are added each year to the total popula-
JoAnne K. Gronley, DPT, is Associate Director of

Research, Pathokinesiology Laboratory, Rancho Los
California.
Jacquelin Perry, MD, is Director Emeritus,
Pathokinesiology Laboratory, Rancho Los Amigos
National Rehabilitation Center, Downey, California.
Top Spinal Cord Inj Rehabil 2008;13(4):86119
2008 Thomas Land Publishers, Inc.
www.thomasland.com
doi:10.1310/sci1304-86
Strategies to Preserve Shoulder Function
tion of approximately 253,000 persons now

living with SCI. SCI occurs most often to the
young adult, between the ages of 16 to 30
years old.1 With improved health care systems, the once dismal life expectancy of the
SCI patient has greatly improved.2 The most
frequent neurological level of injury is incomplete tetraplegia (34.1%), followed by
complete (23.0%) and incomplete (18.5%)
paraplegia, and complete tetraplegia
(18.3%).3 A substantial number of persons
rely on a manual wheelchair as a daily means
of ambulation. Unfortunately, manual
wheelchair use places significant stability
and mobility demands on the upper limbs.
Shoulder Pain in Manual Wheelchair
Users with SCI
Loss of lower extremity function with SCI
places the entire burden of locomotion, transfers, and activities of daily living (ADLs) on
the upper extremities, often resulting in
shoulder pain after as little as 1 year.46 The
prevalence of shoulder pain is notably higher
in individuals with SCI than in the ablebodied population for any age group, 79
higher in persons with tetraplegia than with
paraplegia,4,5,10,11 and higher in women.1214
The duration of SCI,7,8,15,16 older age,17 and
higher body mass index (BMI)4,18 also contribute to the development of shoulder pain.
Several cross-sectional studies have investigated the association of the weight-bearing
activities to shoulder pain in the SCI population.10,11,16,19 In a survey of over 200 individuals with SCI by Curtis et al.,10 the highest
intensities of shoulder pain were reported
during manual wheelchair propulsion
(WCP) on inclines or for longer than 10minutes duration. In a survey of 52 men with
paraplegia, 60% reported upper limb pain
87
with specific ADLs.16 Work or school was the

most frequently reported activity to result in
upper limb pain (52%). Sleep (50%), toilet/
shower transfers (48%), and outdoor wheeling (46%) also were reported to result in arm
pain in a large percentage of respondents.
Even indoor wheeling resulted in pain in more
than a third of the patients. Shoulder and wrist
joints had similar frequencies of involvement
(39% and 40%, respectively), whereas 31% of
persons reported elbow pain.
The relationship between time of SCI and
the development of shoulder pain varies depending on the level of SCI. Among individuals with paraplegia, the incidence increases with the time since injury with a 30%
to 35% rate at 5 years; a full 70% of patients
at 20 years after injury complained of shoulder pain.7 The prevalence of shoulder pain in
persons with tetraplegia was reported to significantly increase in the first few months
after injury and significantly decrease by the
first 5 years after injury4,6 and then increase
after another 10 years of wheelchair use.6,7
The differences in observation between individuals with paraplegia and tetraplegia may
be an important predictor for shoulder pain.4
Etiology and Pathomechanics
The etiology of shoulder pain most commonly is reported to be chronic impingement
syndromes,20,21 chronic orthopedically related inflammatory syndromes,7 acromioclavicular and glenohumeral joint degeneration, 14,22,23 instability, 24 and bicipital
tendinitis.8,21 Three fourths of persons with
long-term paraplegia and shoulder pain were
found to have symptoms consistent with impingement, and 65% to 71% had rotator cuff
tears documented by arthrography or
MRI.20,25 The investigators ascribed the
88
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 2008
shoulder pathology to chronic overuse of

muscles and joint tissue from repetitive impingement of subacromial structures during
WCP, transfer, and weight-relief activities.
In a study of younger individuals with shoulder pain and shorter duration of SCI, the
complete progression to rotator cuff tear was
less frequent.13 Edema and osteolysis of the
distal clavicle and degeneration of the acromioclavicular joint were attributed to repetitive trauma from WCP and transfers and
were present in over two thirds of the subjects. Recently, Mercer et al.26 reported an
association between higher superior forces
and internal rotation moments at the shoulder
with increased signs of shoulder pathology
during the physical exam. This is in agreement with the finding of increased superior
shoulder joint forces during the push phase of
WCP in persons who were asymptomatic at
the time of testing but who would develop
shoulder pain in the following 10 years compared to persons who remained pain free.27
This indicates that an individuals pattern of
WCP can contribute to the risk of developing
shoulder pain after SCI.
Structurally, the shoulder (glenohumeral
joint) is poorly designed for weight bearing,
because the shallow socket for the humeral
ball (glenoid) has only a fibrous labrum for
peripheral stability and the plane of the joint
is vertical. During WCP and depression
transfers, the arms are in low angles of elevation, and the joint capsule is loose and its
reinforcing ligaments are slack. Consequently, shoulder muscles must provide both
joint stability and power for forward propulsion making them susceptible to fatigue.28,29
Decreased muscular force as a result of fatigue or neurological deficiencies can result
in inadequate dynamic stability and allow the
external loads of WCP to induce shear forces
that displace the humeral head upward from

the center of the socket.30,31 This upward
humeral head migration can compress the
subacromial space and the rotator cuff tendons (mainly the supraspinatus), the tendon
of the long head of biceps brachii, and the
subacromial bursae resulting in chronic inflammatory and impingement syndromes7,20
and bicipital tendinitis8 (Figure 1). The
pathomechanic factors contributing to shoulder pain are most likely multiple and interrelated and include extrinsic, intrinsic, and
overuse factors.32,33 In an animal model of
rotator cuff pathology, supraspinatus
tendinosis was more likely to occur with the
combination of mechanical impingement
and muscle overuse than with either factor
alone.32
Consequences of Shoulder Pain and
Pathology
The limitations and restrictions imposed
by shoulder pain in persons with SCI can be
described in the framework defined by the
International Classification of Functioning,
Disability and Health (ICF)34 (Figure 2). The
ICF can be an effective resource for identifying key elements that must be addressed in
rehabilitation interventions.35 In particular,
the concepts of activity limitations and participation restrictions are classified as two
components of the health level of the person
and society. Because individuals with SCI
are dependent on their upper extremities for
both mobility and typical ADLs, shoulder
joint pain can present a devastating loss of
function and independence (activity limitation)5,9,23,36 and decreased quality of life (participation restriction).3740 Sie and coworkers7 postulated that the development of
shoulder pain can limit ability such that it is
89
Figure 1. External loads during weight-bearing tasks induce shear forces to cause an upward
displacement of the humeral head and potential subacromial impingement.
functionally equivalent to sustaining a higher

level of SCI.
In persons who have recently been injured,
quality of life (QOL) has been reported to, at
least temporarily, decrease.38,41 Over time,
psychosocial issues tend to stabilize and
QOL tends to improve.41,42 QOL is negatively impacted when individuals with SCI
experience generalized bodily pain that limits their daily activities.39,40,42 Gutierrez et
al.43 interviewed 80 participants with shoulder pain and identified that higher intensities
of shoulder pain (as determined by Wheelchair Users Shoulder Pain Index [WUSPI]
scores19) were associated with lower subjective QOL scores in persons with paraplegia (r
= 0.35, p = .002) and decreased community
mobility (r = 0.42, p < .001). Thus, it is
imperative to develop strategies for preserving shoulder function in persons with SCI
who use a manual wheelchair.
To maintain a maximal level of activities
and participation, environmental and personal factors listed in the ICF framework
90
Figure 2. The International Classification of Functioning, Disability and Health (ICF) framework
for identifying key elements that must be addressed in rehabilitation interventions to preserve
shoulder function in persons with SCI
must be addressed. The Consortium for Spinal Cord Medicine organized by the Paralyzed Veterans Association (PVA) developed a guideline titled Preservation of
Upper Limb Function Following Spinal
Cord Injury: A Clinical Practice Guideline
for Health-Care Professionals based on
most current scientific and professional information available.44 A multidisciplinary
panel of experts extensively debated the
merit and evidence-based information supporting each of the recommendations. Using
the framework of the ICF, the recommendations put forth in the PVA clinical guideline
are meant to address key elements and strategies aimed at preserving shoulder function
in persons with SCI who use a manual wheelchair as a chief mode of mobility.
Strategies to Preserve Shoulder
Function
The current article presents important research issues for evaluating and decreasing
91
the shoulder demands during wheelchair activities by adopting the recommendations put
forth in the clinical practice guideline44 for
preserving shoulder function in manual
wheelchair users with SCI. These include
environmental factors related to reducing the
mechanical load and muscular demands
through ergonomics, equipment selection,
training, and environmental adaptations and
personal factors related to increasing the capacity of shoulder joint structures to handle
the mechanical loads through strengthening
and exercise. Each recommendation is supported by current research in each relevant
area.
Research on shoulder loads during manual
wheelchair activities
The relatively high magnitudes and frequency of loads during wheelchair propulsion (Figure 3), transfers (Figure 4), weightrelief raises (Figure 5), and overhead
activities have been reported as the source of
primary pain in persons with SCI.9,10,15,20,45
Evaluation of the mechanical load on the
musculoskeletal system is important to an
understanding of the mechanisms that may
cause shoulder pain and pathology. Measurement technology is required given the needed
detail and accuracy for quantifying the physiology and biomechanics used during wheelchair activities. Technological developments
in these areas have made available fast and
precise measurement technology such as electromyography, metabolic analyzers, motion
sensors, and force transducers and biomechanical models of the upper extremity segments and shoulder complex that allow detailed study of the shoulder loads during
wheelchair activities. Functional evaluation
of wheelchair activities has often been conducted in a laboratory setting on treadmills
Figure 3. Start of the push cycle during wheelchair propulsion by a manual wheelchair user
with SCI.
and ergometers (Figure 6). These setups

allowed repeated and specific evaluation of
the kinematics, kinetics, power and work,
technique, and efficiencies during wheelchair
propulsion, raises, and transfers. This has led
to the development of evidence-based guidelines for preserving upper extremity function
in the person with SCI during wheelchair
activities, including prescriptions for ergonomics, equipment selection, userwheelchair interface, propulsion and transfer techniques, and exercise prescription. To prevent
further loss of functional independence, it is
imperative to find ways to reduce the strain
and joint deterioration that may occur with
long-term upper extremity weight bearing.
Because options are limited once injury occurs, the most damaging activities must be
identified to guide recommendations for preventing such injury. Recent advances in
92
Figure 4. (A) Starting position with the participant sitting in a wheelchair and hands positioned for
depression transfer maneuver. (B) Preparation phase of depression transfer maneuver; body weight
has shifted from buttocks unto hands. (C) Mid-transfer position where peak elbow posture was used
to separate the lift and descent phase. (D) Final position with participant sitting on examining table.
In all positions, the trailing arm is on the wheelchair and the leading arm is on the table. Reprinted,
with permission, from Perry J, Gronley JK, Newsam CJ, Reyes ML, Mulroy SJ. Electromyographic
analysis of the shoulder muscles during depression transfers in subjects with low-level paraplegia.
Arch Phys Med Rehabil. 1996;77(4):350355. Copyright 1996 by Elsevier.
93
Figure 5. (A) Starting position of a weight-relief raise: person with low paraplegia at the beginning
of the initial loading phase. (B) End position of the weight-relief raise: person with low paraplegia
during the hold phase. Reprinted, with permission, from Reyes ML, Gronley JK, Newsam CJ,
Mulroy SJ, Perry J. Electromyographic analysis of shoulder muscles of men with low-level
paraplegia during a weight relief raise. Arch Phys Med Rehabil. 1995;76(5):433439. Copyright
1995 by Elsevier.
monitoring devices that use miniaturized

sensors, wireless, and data logging technology promise to allow longitudinal evaluation
of the physiology and biomechanics in a
more natural environment. Development of
biomechanical models of the shoulder from
simple link segment models to more elaborate models that estimate composite shoulder
muscle and internal contact forces as a function of segment and bone kinematics and
external forces affords a greater depth of
understanding regarding the causal relationship between shoulder loading during wheelchair activities and shoulder pain and pathology. Future research will need to focus on
linking the mechanical loads, long-term ex-
posure, and the effects of preventive measures aimed at preserving shoulder function
in the manual wheelchair user with SCI.
Electromyography (EMG)
Simultaneous recording of muscle activity

using indwelling fine wire or surface electrodes allows detailed studies of the demands
on the specific muscles or groups of muscles
involved in WCP.28,29,46,47 The EMG activity
patterns of the deltoid, rotator cuff, and deep
and superficial scapulothoracic muscles provide critical insights to the mechanism of
shoulder pathology in long-term, spinal
cordinjured wheelchair users.28,29 In participants with paraplegia, high-intensity activity
94
Figure 6. Pushrim instrumented with strain gauge force transducers placed on a wheelchair
ergometer consisting of supporting frame, controlling computer, and split roller. Reflective
markers placed on participants bony landmarks for quantifying upper extremity kinematics
during propulsion.
was recorded in the sternal pectoralis major

and supraspinatus muscles29 (Figure 7). Durations of 60% to 70% of the propulsion cycle
were identified in the recovery phase
muscles. Supraspinatus showed both push
and recovery patterns leading to almost continuous activity in some participants. This
intensity and duration of muscle activity has
a limited endurance time.48 The muscles that
provide depression and stability of the humeral head during WCP are particularly vulnerable. The limited propulsion capability of
the participants with tetraplegia was manifested in the EMG patterns with markedly
increased durations and intensities.28 Their
loss of sternal pectoralis major function

meant that they relied on the anterior deltoid
to provide the forces for forward propulsion.
Subscapularis and latissimus dorsi shifted
their primary activity to include the push
phase to augment the medially directed force
required for propulsion with impaired hand
grip and to mitigate the upward pull of anterior deltoid in the absence of sternal pectoralis major. Consequently, even though the
external forces are lower, the tetraplegic
shoulder is more vulnerable.
The critical muscles involved in depression raises and transfers in persons with
paraplegia and tetraplegia were identified
95
activity (31% to 81% maximum) during

transfers and raises that is compatible with
only brief duration before fatigue. The rotator cuff musculature is minimally active during the depression raise but participates with
moderate intensity during transfers. Intramuscular electrodes were used to document
and compare the intensity (percent Max
Muscle Test [MMT]) of 12 shoulder muscles
of the trailing and leading arms while asymptotic persons (n = 12) with paraplegia were
transferring to and from a wheelchair.50
Three phases of the transfer were analyzed:
preparation, lift, and descent. The intensity
of muscle activity was greatest during the lift
phase and least during the preparation phase
for all muscles.
Kinematics
Figure 7. (A and B) Two consecutive cycles of

raw EMG from a representative participant.
The wheel torque that designates the push
phase is displayed at the bottom. Reprinted,
with permission, from Mulroy SJ, Gronley JK,
Newsam CJ, Perry J. Electromyographic activity of shoulder muscles during wheelchair
propulsion by paraplegic persons. Arch Phys
Med Rehabil. 1996;77(2):187193. Copyright 1996 by Elsevier.
using EMG analysis.4955 The large thoracohumeral muscles, sternal pectoralis major and latissimus dorsi, provide the force to
raise the trunk on the arms. With origins on
the thorax and insertions on the proximal
humerus, the compressive and downward
force of these muscles provides dynamic
protection of the shoulder joint. These
muscles exhibited moderate to high intensity
Kinematics of the upper extremities during wheelchair activities are generally determined using anatomically relevant markers
and a coordinate system representation of the
glenohumeral joint 5660 or the shoulder complex including the scapula.6163 Kinematic
variables provide a stable means to characterize upper limb motion, movement frequency, and propulsion patterns (e.g., cycle,
push, recovery duration, stroke pattern56,57,6468)
with different SCI levels and impairments69
71
and to determine optimal wheelchair configurations and design.7275 Evaluation of the
kinematics of the trunk and upper extremities
during transfers,53,55 raises,52 and overhead
reaching76 can identify movement patterns
that place the shoulder at a greater risk for
injury and guide strategies for optimizing
shoulder motion patterns.
Reaction Forces
Determining the force impact during WCP

and related activities requires instrumented
96
wheels68,7779 or an ergometer80 to accurately

measure three-dimensional reaction forces
and moments on the hand during WCP, transfers, and raises. Instrumented handrims have
been used in documenting the distribution of
propulsive forces at different speeds and resistances,8183 identifying optimal wheelchair
configuration,8486 and examining the effectiveness of propulsion with different
strengths and levels of SCI.87,88 One commercially available instrumented handrim system (SMARTWheel; Three Rivers Holdings LLC, Mesa, AZ) enables collection of
the reaction forces and moments while users
propel their wheelchair. The SMARTWheel
has been evaluated in several studies8991 and
is currently utilized in a multicenter study
relating propulsion biomechanics and upper
limb injury.92
Joint kinetics
Evaluation of the joint kinetics can identify excessive loading patterns that may predispose the shoulder to injury during WCP,
transfers, and weight-relief raises. Quantitative assessment of the mechanical loads on
the shoulder joint, net moments and forces
(joint kinetics) of the upper extremities, is
generally calculated with a Newton-Euler
linked-segment inverse dynamics procedure.93,94 To demonstrate the magnitude of
loading at the shoulder, studies have reported
the net joint forces and moments during
wheelchair propulsion at various speeds and
power output,58,82,95 on levels and ramps,79
and during exercise and fatigue states.96,97
Kinetic analysis has also been used to evaluate differences in mechanical loading in persons with different levels of SCI,98 levels of
experience,99 and wheelchair configurations.100,101 Further, evaluation of the glenohumeral contact forces and shoulder muscle
forces was performed by Veeger et al.102 and

van Drongelen et al.103 using the Delft shoulder and elbow model104 consisting of 31
muscles divided into 139 muscle elements.
During low-intensity propulsion, they determined that peak glenohumeral contact forces
ranged from 350 N (estimated), 800 N, and
1400 N at 4.6 W (0.83 m/s), 10W (0.83 m/s),
and 20 W (1.39 m/s) external loads (speed).
The muscles estimated to produce the largest
peak forces during the push phase were the
monoarticular part of the triceps brachii, the
deltoideus muscles, the supraspinatus, and
subscapularis. More recently, the magnitudes and directions of these net joint forces
and moments were examined in relation to
shoulder pain27 and pathology.26
Metabolic energy
Early studies on WCP documented that

the higher rate of energy expenditure (33%
greater than normal) attested to the increased
arm work involved.105,106 Metabolic energy
measures have since been used to document
the reduced energy demands of propelling
ultralight versus lightweight wheelchairs,107
to document that alternative propulsion designs reduce the energy demands of WCP,108
113
to show that lower wheelchair seat height
improves effeciency,73 and to determine
which tires and tire pressure settings require
the least effort during propulsion.114 Energy
expenditure recording also demonstrated
that propelling in a side slope increases energy requirements115 and that an individuals
stroke pattern during WCP is related to efficiency.116,117
Activity monitors
Evaluation of the mechanical loads during

wheelchair use in relation to daily activities
and lifestyle requires monitoring outside the
laboratory and in the home and community.

Continuous monitoring has become more
feasible due to the development and miniaturization of monitoring devices, portable
metabolic analyzers, and motion-sensing
technology. Accurate monitoring of wheelchair activities outside the laboratory is a
critical component in establishing evidencebased interventions to preserve shoulder
function. Quantitative measures of activities
in the home and community provide a means
to relate objective physiological measures
from clinical and laboratory environments to
subjective aspects of independence, QOL,
and participation level. Activity monitors
have been used to quantify ambulatory activities including wheeling.118 Using a custom wheelchair data activity logger, Tolerico
et al.119 investigated the mobility characteristics and activity levels of manual wheelchair
users in the residential setting and at the
National Veterans Wheelchair Games
(NVWG) over a period of 13 or 20 days.
They found that users traveled a mean SD
of 2,457.0 1,195.7 m/d at a speed of 0.79
0.19 m/s for 8.3 3.3 h/d while using their
primary wheelchair in the home environment. These types of studies provide a better
understanding of the individuals activity
levels and may provide insights into the activities that may predispose the shoulder to
harmful situations. Future development
should focus on identification of quantification of high-demand activities including
WCP, transfers, raises, and overhead reaching tasks monitored at home and in the community.
Ergonomics
Minimize the frequency of repetitive upper limb tasks and reduce the forces required to complete the task. Based on cur-
97
rent ergonomic literature, repetitive performance of the tasks and high forces associated
with each task place added demands on the
shoulder and have been implicated as risk
factors for strain injury and/or pain during
occupational activities.120122 The demands
on the shoulder of manual wheelchair users
with SCI during WCP and related activities
are similarly dictated by the frequency of
repetition of upper limb tasks and the forces
required for completing the tasks. In particular, the most strenuous activities for manual
wheelchair users are entering or leaving a
car, ascending ramps, performing heavy lifting with arms, and propelling wheelchairs
outdoors. The frequency of repetitive upper
limb tasks can be described by the number of
propulsive strokes to maintain a required
velocity during WCP, the number of transfers and weight-relief raises performed, and
other overhead tasks at work and home environment.
During WCP, almost 50% of the forces
exerted at the pushrim are not directed toward forward motion and, therefore, these
forces either apply friction to the pushrim or
are wasted. Boninger et al.81 described the
forces and moments occurring during wheelchair propulsion on a dynamometer at 1.3
and 2.2 m/s in persons with paraplegia. They
determined that the tangential, radial, and
medial-lateral forces were found to comprise
approximately 55%, 35%, and 10% of the
resultant force, respectively. With increased
speed, stroke and push time decreased; the
peak force tangential to the pushrim, peak
moment radial to the hub, maximum rate of
rise of the tangential force, and maximum
rate of rise of the moment about the hub
increased with speed. This low mechanical
efficiency of WCP is one of the factors explaining the high peak physical strains in
98
daily activities of manual wheelchair users.123 To investigate the mechanical efficiencies during WCP in persons with tetraplegia and paraplegia, Dallmeijer et al.88
calculated the fraction of effective force
(FEF; defined as the ratio of tangential force
and total force) at two different submaximal
intensity conditions. Results showed that the
low FEF in persons with tetraplegia underlines the ineffective way they apply the force
to the handrim. This low FEF is mainly the
consequence of a larger lateromedially directed force component, which is most likely
a result of reduced muscle function in sternal
pectoralis major and triceps brachii, and the
loss of hand grip function, which necessitates
extra handrim friction to propel the wheelchair.
Kulig et al.95 quantified the forces and
moments at the shoulder joint during free,
level wheelchair propulsion and documented
changes imposed by increased speed and
inclined terrain in men (N = 17) with lowlevel paraplegia. During free propulsion,
peak shoulder joint forces were in the posterior (46 N) and superior directions (14 N),
producing a peak resultant force of 51 N at an
angle of 185 (180 = posterior). Peak shoulder joint moments were greatest in extension
(14 Nm), followed by abduction (10 Nm) and
internal rotation (6 Nm). With fast and inclined propulsion, peak vertical force increased by more than 360% (Figure 8), and
the increase in posterior force and shoulder
moments ranged from 107% to 167%. The
increased joint loads documented during fast
and inclined propulsion as well as during
fatigue could have harmful changes due to
repetitive compression of subacromial structures against the overlying acromion. Further, Kulig et al.98 calculated the joint kinetics
during the push phase of WCP in persons
Figure 8. Mean vertical shoulder net joint

forces during free propulsion, fast propulsion,
and 8% incline propulsion.
with paraplegia and tetraplegia and determined that the superior push force in persons
with tetraplegia was significantly higher than
in those with high paraplegia, after covarying
with velocity. The pattern of increased superior push forces and high rotator cuff muscle
activity, coupled with weakness of thoracohumeral depressors seen in persons with tetraplegia, has the potential to increase susceptibility of the subacromial structures to
compression and increase the risk for muscle
damage, such as rotator cuff tears.
In evaluating the mechanical load during
wheelchair activities, van Drongelen et al.79
compared the shoulder net joint moments
during WCP (level and slope propulsion),
weight-relief lifting, reaching, and negotiating a curb by able-bodied persons (n = 5) and
by persons with paraplegia (n = 8) and tetraplegia (n = 4). Peak shoulder and elbow
moments were significantly higher for negotiating a curb and weight-relief lifting than
for reaching, level propulsion, and riding on
a slope. Comparison of the glenohumeral
contact forces and shoulder muscle forces
during level propulsion, weight-relief lifting,
and reaching from the same participants
showed peak contact forces were significantly higher for weight-relief lifting compared with reaching and level propulsion.
High relative muscle force of the rotator cuff
was reported; it was apparently needed to
stabilize the joint. For weight-relief lifting,
total relative muscle force was significantly
higher for the tetraplegia group than for the
able-bodied group.103
Two studies have examined the association between the biomechanics of WCP and
shoulder pathology in manual wheelchair
users.26,27 Mercer et al.26 examined individuals (N = 33) with paraplegia propelling at 0.9
m/s and 1.8 m/s. Shoulder pathology was
evaluated using physical exam and MRI.
They determined that persons who experienced higher net joint posterior force, lateral
force, or extension net joint moment during
propulsion were more likely to exhibit
coracoacromial ligament edema. Those who
had larger lateral net joint forces or abduction
net joint moments were more likely to have
coracoacromial ligament thickening. Higher
superior forces (compressive) and internal
rotation joint moments were associated with
increased signs of shoulder pathology during
the physical exam. They indicated a need to
reduce the overall force required to propel a
wheelchair to preserve upper limb integrity.
In a small pilot study, Mulroy et al.27
identified several differences in WCP biomechanics in persons (n = 6) who would
eventually develop shoulder pain compared
with persons (n = 5) who remained pain free
over a 10-year follow-up period. Despite a
similar velocity, persons who developed
pain had increases in cadence, vertical shoulder joint force, and intensity and duration of
EMG in the primary push phase muscles at
the shoulder. The pattern of force application
on the pushrim also was different in the two
99
groups. Participants who later developed

shoulder pain had a smaller push arc with a
more forward initial hand placement and a
greater vertical force on the pushrim. Peak
vertical shoulder joint force had a moderate
correlation with cadence and was negatively
correlated with push arc.
During WCP, the frequency and forces
can be minimized through equipment selection particularly the use of lightweight
wheelchairs and components, use of alternative manual propulsion or power devices
when appropriate, and avoidance of environmental barriers that make propelling strenuous (e.g., traversing ramps, side slopes, going over uneven surfaces). Additionally,
individualized adjustments to optimize the
userwheelchair interface including horizontal and vertical seat position relative to
the wheelchair axle and a seating system that
promotes appropriate posture and balance
should be adopted. A lower frequency of
transfers, raises, and overhead arm activity
tasks can help prevent strain or injury. The
forces required to transfer into and out of the
wheelchair can be reduced through optimal
transfer mechanics and use of assistive technology, such as sliding transfer boards (Figure 9).
Minimize extreme or potentially injurious positions at the shoulder by avoiding
extreme positions such as hand over the
shoulder. Based on ergonomics literature,
there is a strong association between working above overhead height and shoulder pain
in the work environment.124,125 Use of a
wheelchair increases a persons need for
overhead activity to access the environment.
To compare frequency and duration of overhead arm activity between wheelchair users
and control participants who do use a wheel-
100
Individuals with SCI should avoid extreme

shoulder positions, particularly overhead
arm activities. This can be accomplished by
modifying the home and work environments
and using appropriate assistive technologies
(i.e. reachers; Figure 10).
Figure 9. Use of a transfer board as a means to

minimize shoulder force to complete the
transfer task.
chair during an 8-hour workday, we evaluated five manual wheelchair users and five
occupation-matched, control participants
using an accelerometer-based activity monitor.76 Control participants had an average of
53 episodes of overhead activity during the
8-hour workday (range = 9 to 88). By comparison, wheelchairs users had an average of
297 episodes of overhead arm activity during
the same time period (range = 44 to 798). The
total time spent in an overhead position was
more than five-times greater for manual
wheelchair users (mean = 34.6 minutes;
range = 7.9 to 106.6 minutes) compared with
ambulatory control participants (mean = 6.6
minutes; range = 0.4 to 15.5 minutes). From
this preliminary study, we determined that
manual wheelchair users perform more overhead activities than occupation-matched control participants. The increased overhead use
documented in this study among wheelchair
users may also contribute to the development
of shoulder pathology in persons with SCI.
Minimize extreme or potentially injurious positions at the shoulder by avoiding

extreme internal rotation and abduction.
Newsam et al.70 identified the differences in
patterns of shoulder motion as a function of
injury level by comparing three-dimensional
upper extremity kinematics using a global
coordinate system126 during the push and
recovery phases of WCP in persons with four
levels of SCI: low paraplegia, high paraplegia, C7 tetraplegia, and C6 tetraplegia. The
average peak humeral elevation (57.1 vs.
49.5) as well as total joint excursion (35.7
vs. 28.4) were significantly greater in persons with low paraplegia than C6 tetraplegia,
indicating that the magnitudes of the motion
were generally greater in persons with
paraplegia compared to tetraplegia even
though the shoulder motion patterns were
similar between groups.
Differences in motion patterns at the elbow and wrist were most often related to the
strategy in which the pushrim was contacted.
In comparing the joint kinematics and temporal characteristics of asymptomatic
manual wheelchair users propelling at one
speed (3.4 km/h), Finley et al.71 reported that
participants with upper limb impairment propelled with a higher stroke frequency (1.2 vs.
1.5 cycles/s), reduced handrim contact time
(44.6% vs. 37.1% cycle), and smaller peak
joint angles and joint excursion of the wrist,
elbow, and shoulder during the contact phase
than individuals with intact upper limb function. They concluded that the reductions in
101
Figure 10. (A) Modifications in the home and work environment and use of (B) reachers in order
to avoid extreme shoulder positions, particularly overhead arm activities.
these kinematic variables may be an adaptive

mechanism for maintaining functional independence, and some of these adaptations
ultimately may protect the user from the
development of secondary upper limb impairment.
The classic position for impingement is
when the arm is internally rotated, forward
flexed, and abducted.127 Internal rotation and
abduction are common positions during
WCP. Newsam et al.70 indicated that the
marked posterior plane with internal rotation
position of the humerus at initial contact
places the greater tuberosity and supraspinatus tendon close to the acromion, increasing
the potential for impingement. Theories regarding the mechanism for impingement
have been linked to reduction in the available
subacromial space, thereby entrapping soft
tissue structures and creating or intensifying
shoulder pathology through increased subacromial pressure and/or frictional forces.128
As the limb is loaded during the subsequent
early push phase, high loads are experienced
by the shoulder joint while the humerus position is relatively unchanged. For individu-
102
als with paraplegia, glenohumeral joint protection is provided by the activity of the
sternal portion of the pectoralis major that
contributes to humeral head depression. This
joint protection is lost, however, in persons
with C6 tetraplegia because of pectoralis
major weakness. Evaluation of the shoulder
complex kinematics using an electromagnetic tracking device during the transfer and
weight-relief raise in persons without disability (n = 25) illustrated how the scapular
and humeral positions and directions of motion may negatively impact the available
subacromial space.129 During the weight-relief raise, scapular upward rotation increased
from the preparatory to the beginning of the
lift phase (5o), but then decreased (13o) at the
hold phase. The scapula was also more internally rotated (5o) and more anteriorly tipped
(6o) for the hold phase as compared to the
preparatory phase. The humerus showed reduced external rotation (20o), moving to only
4o of external rotation in the hold phase. During wheelchair transfer, the leading arm
showed 3o greater scapular anterior tipping
and internal rotation and less scapular upward
rotation and humeral external rotation than the
trailing arm during the final phase of the
transfer. It was indicated that the last phase
(sit-back) corresponded to the point of transfer
when the participants rotated their trunks toward their supporting extremity while maximally loading the upper extremities. This
represented a critical point when the individual must have the strength and control to
balance the trunk mass between extremities.129 It is recommended that manual wheelchair users minimize extreme internal rotation and abduction during WCP and transfers
through proper equipment selection (lightweight wheelchairs) and configuration (axle
positioning and seating system) and by
avoiding strenuous environmental barriers

(ramps, side slopes, uneven transfers).
Equipment selection
Recommend a high-strength, fully

customizable manual wheelchair made of
the lightest possible material. Use wheels
and tires with least rolling resistance.
Manual wheelchairs are generally grouped
into three categories: depot (35 lbs or more),
lightweight (30 to 35 lbs), and ultralight (less
than 30 lbs). Lighter chairs require less effort
to propel, are adjustable, and are made of
stronger, higher grade materials. Overall,
lightweight chairs cost less to operate,130 because they last longer131 and are more durable.132 Additionally, use of castor wheels
and tires that minimize the rolling resistance
will minimize the forces during WCP.133 Propelling a lightweight wheelchair was shown
to be more efficient than propelling a standard wheelchair. The energy cost of propelling the lightweight chair at a specific velocity was 17% less than that of the depot chair.
The greater efficiency of the lightweight
wheelchair was attributed to differences in
wheelchair design in addition to the total
mass of the device.134 Beekman et al.107 determined the energy cost of WCP in people with
SCI, comparing 20-min self-selected propulsion on an outdoor track in an ultralight and
lightweight wheelchair by persons with
paraplegia (n = 44) and tetraplegia (n = 33).
Speed, distance travelled, and energy cost
(VO2 = mL/kg/m) were compared by wheelchair, group, and over time. In the ultralight
wheelchairs compared to the heavier chairs,
speed and distance traveled were greater for
both paraplegia and tetraplegia participants,
whereas oxygen cost was less only for persons with paraplegia; this shows that persons
with tetraplegia, particularly at the C6 level,

are limited in their ability to propel even
ultralight weight wheelchairs. Sawatzky et
al.,114 in comparing the rolling resistance
differences of five commonly used wheelchair tires (three pneumatic and two solid)
under four different tire pressures (100, 75,
50, and 25 of inflation), determined that solid
tires (no-more flats) had greater rolling
resistance than all three pneumatic tires even
when tires were underinflated to 25% of tire
pressure. Furthermore, energy expenditure
measures in 15 participants with paraplegia
during wheelchair propulsion showed that tire
deflation significantly increased energy consumption at 50% of tire inflation. New developments of ultralightweight, carbon fiber
based hub and spoke wheels (e.g., Spinergy;
Spinergy, Inc., Lyons, CO) provide greater
strength, better shock absorption, and a more
comfortable ride than traditional steel spoke
wheels.135 Incorporation of these research
findings into routine clinical practice will help
remove the barriers preventing full reimbursements for these equipments.136
Consider alternative propulsion designs for users with shoulder weakness
and/or pain. Use of an alternative propulsion design has the potential to preserve the
shoulders of people at risk for overuse injury
and allow them to maintain a more optimal
level of activity and independence. The
pushrim-activated power-assisted wheelchair (PAPAW) offers an alternative mode
of manual propulsion for marginal users
with SCI.111 The power unit provides additional power to the propulsion effort, resulting in a considerable reduction in the required push force during WCP. Two
PAPAWs are currently commercially available, the e.motion (Albers, Frank Mobility,
103
Inc., Oakdale, PA) and Quickie Xtender

(Sunrise Medical Inc., Longmont, CO), each
with a unique mechanism of assistance delivery. Evaluation of PAPAW performance in
the laboratory (ergometer propulsion) has
shown that it reduces user power requirements by 56% to 79%,112 reduces metabolic
energy consumption by 17% to 43%,113 and
improves mechanical efficiency by about
80%. Evaluation of upper extremity joint
range of motion during PAPAW propulsion
at three resistance levels and two speeds on
an ergometer demonstrated reduced excursion compared to standard ultralight WCP at
a similar cadence.75 During prolonged propulsion over an outdoor track, PAPAW has
been demonstrated to reduce heart rate and
oxygen consumption while increasing selfselected velocity over a 20-minute period.109
Cooper et al.111 reported that participants
pushing over a five-task ADL obstacle
course had an overall decrease in heart rate
and oxygen consumption with PAPAW, in
addition to receiving a higher ergonomic
rating during all ADLs except loading the
rear wheels into a car. Levy et al.137 similarly
found in elderly wheelchair users traversing
a level surface, carpet, and an incline that the
PAPAW reduced heart rate and perceived
exertion, in addition to decreasing upper extremity surface EMG.
To determine more specifically the propulsive demands on the key shoulder
muscles providing the propulsive effort, we
evaluated a PAPAW in a group of full-time
manual wheelchair users with complete tetraplegia (N = 14). 138,139 Wire electrodes recorded muscle activity from anterior deltoid
(ADELT), pectoralis major (PECT), supraspinatus (SUPRA), and infraspinatus
(INFRA). Participants first pushed a standard ultralight wheelchair on an ergometer at
104
Figure 11. Electromyographic (EMG) activity

of ADELT, PEC, SUPRA, and INFRA during
simulated 8% graded propulsion with a standard wheelchair and a PAPAW from a participant with C-7 tetraplegia. Solid bars indicated
push phase.
self-selected free and fast speeds and then up

a simulated 4% graded incline. They then
pushed a Quickie Xtender PAPAW on the
ergometer and attempted to match their standard wheelchair free, fast, and graded propulsion. During matched free propulsion,
velocity, cadence, and cycle length were
similar between the two wheelchairs. During
matched fast PAPAW propulsion, velocity
was statistically but not clinically significantly reduced, with significantly decreased
cadence and increased cycle length compared to the standard wheelchair. During the
matched graded trial, PAPAW velocity was
significantly faster than the standard wheelchair. Participants maintained a similar cadence but significantly increased their cycle
length in the PAPAW. We found that in
participants with tetraplegia, PAPAW propulsion significantly decreased push phase
shoulder muscle activity compared to propulsion in the standard wheelchair (Figure

11). During matched free (low-intensity)
propulsion, PAPAW decreased EMG of
ADELT and PECT by 90% to 100%, in
addition to decreasing peak intensity of INFRA. During matched fast and graded propulsion (the higher intensity conditions),
PAPAW substantially reduced activity of all
muscles by 40% to 100%. The data collected
in this study suggest that the power assistance provided by PAPAW reduces shoulder
demands by presumably decreasing the necessary force applied to the pushrim (suggested by the reduction in EMG activity by at
least 50%) as well as potentially reducing the
required frequency of pushing (cadence).
The benefits of PAPAW appear to be enhanced under higher intensity propulsion
conditions. Substituting a PAPAW for a
standard manual wheelchair has the potential
to substantially prolong shoulder joint function for individuals with SCI or other disabilities, while maintaining many of the benefits of manual propulsion.138,139
Consider the use of a transfer-assist device for all individuals with SCI. Strongly
encourage individuals with arm pain and/
or upper limb weakness to use a transferassist device. Assistive devices have the potential to reduce the shoulder forces required
to complete the self-transfer tasks. During
independent transfers, the individual must
not only support the entire body weight but
must also control center of mass displacement with an outstretched hand, which
places the shoulder at risk for injury. Persons
with upper extremity weakness and/or shoulder pain can particularly benefit from the use
of a transfer-assist device such as a sliding
board with a friction-reducing material,140 as
well as orthotic transfer devices that reduce

the effort required for lateral movement.141 In
investigating the influence of a prototype
trunk orthosis to assist transfers and reaching
in an individual with C6 tetraplegia, Allison
et al.141 reported that the trunk orthosis altered the sitting posture of the individual by
allowing him to sit forward with a more
extended lumbar and lower thoracic spine,
which provided a mechanical advantage for
the shoulder depressors to lift the pelvis.
Furthermore, during the reaching task, there
was a significant increase in the reach distance past the knee. Sliding board transfers
also allow the transfer movement to be broken down into smaller movements, which
reduces the required forces and prevents
placement of the shoulder into extreme positions. The ability of various devices to reduce
the forces required for transfers was examined by comparing the push forces (measured using a hand-held dynamometer) required to move passive seated participants
across a horizontal surface when four different methods were used: a vinyl-covered
foam mat, a vinyl sliding board (Ross Easy
Glide), a fabric tube (Ross Mini-Slide; Ross
Medical Equipment AB, Sollentuna, Sweden), or a fabric tube on top of a sliding board
on top of the mat.140 They determined that
sliding board and the fabric tube were most
effective in reducing the push force when
used together. While sliding boards are the
most portable assistive device currently
available, their use during transfer into and
out of an uneven height (such as a truck or
SUV) is not suitable. In this case, appropriate
transfer training and technique should be
recommended.
Userwheelchair interface
Adjust the rear axle as far forward as
105
possible without compromising the stability

of the user. Several studies have documented
that a more forward axle position decreases
rolling resistance,142 increases the amount of
contact with the pushrim,72,84 requires less
muscle effort,46,72 produces a smoother joint
excursion and reduces propulsive stroke frequency,72,84 and improves joint kinetics.100 To
investigate the effect of users position on
pushrim kinetics, Boninger et al.84 measured
the peak and rate of rise of the resultant hand
force during WCP in relation to the users
own axle position setup relative to the shoulder. They found that users with a more posterior axle relative to the shoulder had more
rapid loading of the pushrim. Furthermore,
having the axle in a more rearward position
was related to an increased stroke frequency
and decreased push angle.
To evaluate the effect of fore-aft seat position on shoulder joint kinetics, particularly
compressive loads, Mulroy et al.100 evaluated
the shoulder joint kinetics in male wheelchair users with paraplegia (N = 13) propelling a test wheelchair in two fore-aft seat
positions (axle aligned to shoulder vertical
and seat/shoulder moved 8 cm posterior to
axle) during free, fast, and graded conditions.
For all test conditions, the superior component of the shoulder joint resultant force was
significantly lower in the seat-posterior position. During graded propulsion, the posterior
component of the shoulder joint force was
significantly higher with the seat posterior.
Peak shoulder joint moments and power
were similar during free and fast propulsion.
During graded propulsion, the seat-posterior
position displayed increased internal rotation moment, decreased sagittal plane power
absorption, and increased transverse plane
power generation. This investigation provides objective support that a posterior seat
106
Figure 12. Illustration of the difference in push

arc and electromyographic (EMG) activity of
the anterior deltoid during free propulsion in
(A) seat anterior position and (B) seat posterior
position.
position (axle moved forward) reduces the

superior component of the shoulder joint
resultant force. Consequently, this intervention potentially diminishes the risk for impingement of subacromial structures.
The effect of the fore-aft seat position on
the shoulder muscular demands during WCP
was documented for a group of participants
with complete paraplegia.46 Moving the seat
so that the shoulder was 8-cm posterior to the
wheel axle reduced the muscular demand of
wheelchair propulsion (Figure 12). EMG
collected from the push phase muscles of the
participants with paraplegia displayed a reduction in relative EMG intensity for the
pectoralis major and anterior deltoid muscles
responsible for generating the primary propulsive forces (Figure 12). Pectoralis major
demonstrated a reduction in both median and
peak intensity in all conditions. The magnitude of the reductions was clinically as well
as statistically significant (25% to 40% in
free, 30% in fast, and 20% in graded propulsion). Anterior deltoid had a more variable
response. Peak and median intensity were
lower in the posterior position in all conditions but only reached statistical significance
during fast propulsion. Alteration of seat
position had minimal effect on the rotator
cuff muscles studied and did not affect the
duration of muscle activity. Decreased EMG
intensity of the critical humeral depressors
(pectoralis major) without an adverse increase in other muscular effort suggests enhanced endurance capabilities and greater
glenohumeral protection during prolonged
periods of WCP.
Position the rear axle so that when the
hand is placed at the top dead-center position on the pushrim, the angle between the
upper arm and forearm is between 100 and
120. Previous investigations have found
that changes in seat height have significant
effects on WCP joint kinematics,47,72,73,143
handrim kinetics,84,85,143 gross mechanical
efficiency,73 and EMG.47 van der Woude et
al.73 determined that mechanical efficiency
in non-wheelchair users appeared higher at
the lower seat heights of 100 and 120
elbow extension. This is reflected in increased oxygen consumption at seat heights
of 140 and 160 elbow extension. Simultaneously, the excursion of joint motion during
the push phase showed a 15 to 20 decrease
with increasing seat height, which is reflected in decreased push duration. In the
push phase, decreases in extension and abduction/adduction of the upper arm were
seen. The trunk shifted further forward, and
motion in the elbow joint shifted toward
extension with increasing seat height. Masse
et al.47 determined that the joint motions of
the upper limbs were smoother for the low
seat positions when compared to the high

seat position, because they reached extension in a sequence (wrist, shoulder, and elbow) and the degrees of contact were lengthened. Further, lowering the seat position
resulted in less EMG of the primary muscles
for wheelchair propulsion. Similarly,
Boninger et al.84 determined that a lower seat
position increased the push angle at multiple
speeds; thus increasing the push angle increases the time that force is imparted to the
pushrim. Consequently, reduction in cadence was observed. Although wheelchair
users may benefit from a lower seat height to
improve temporal variables, there may be a
trade-off in the increase in nonpropulsive
forces. Kotajarvi et al.85 examined the effect
of seat height on handrim kinetics in participants with paraplegia using a custom-designed axle to change the seat position. They
determined that a shorter distance between
axle and shoulder (low seat height) improved
the push time, recovery time, and push angle.
However, axial and radial handrim forces
were higher in the lowest seat position. This
implied that more nonpropulsive forces are
being imparted to the handrim when the seat
position becomes too low.
Promote an appropriate seated posture
and stabilization relative to balance and
stability needs. Individuals with SCI perform almost all daily functional activities in
a seated position. An appropriate seating
system provides a stable base for lifting,
carrying, and, most important, propelling a
wheelchair. The typical position of the trunk
during WCP, working at a desk, or performing manual tasks is 30 of forward flexion. In
the execution of daily functions, an individual with SCI and paralysis of the trunk
musculature must constantly make adjust-
107
ments and corrections to maintain sitting

balance, demonstrating the inseparable connection between dynamic sitting posture and
function. Without a stable base, the shoulder
may be placed in extreme positions and required to accommodate larger loads to compensate for the unstable trunk. Sitting posture
and balance are influenced by factors including age, SCI level, type of activities, and
preexisting conditions. Individuals with tetraplegia and high paraplegia, almost entirely
at the mercy of gravity during sitting, are
observed to assume an abnormal sitting posture, often referred to as a C-sitting posture.
This posture is characterized by a long Cshaped kyphotic thoracolumbar spine, an
overly extended cervical spine, a flattened
lumbar spine, and a posteriorly tilted pelvis.
This posture is used to compensate for trunk
instability during bimanual activities, but it
may lead to negative biomechanical events
that potentially contribute to chronic pain.
For the manual wheelchair user with SCI,
seating and postural support can affect both
WCP and transfers. A high backrest may be
necessary to provide adequate trunk support,
but it must allow for scapular movement
during WCP. A smaller seat-to-back angle
can improve pelvic stabilization but can
make transfers difficult. Similarly, cushions
should be lightweight to minimize shoulder
forces during WCP but provide a stable support during transfers. It is recommended that
the pelvis should first be stabilized; a cushion
mounted on a firm surface provides postural
support as well as optimal pressure distribution and comfort. Enhance balance for the
performance of ADLs by promoting a neutral and midline pelvic position and a midline
trunk, with normal lumbar and cervical lordosis, for persons without fixed deformities
and sufficient trunk control. Trunk support
108
should be placed as high as needed to promote stability and comfort, and anterior and
lateral support should be used if an individual
is unable to maintain a stable posture when
performing functional tasks. Adjustments
should be made for persons with tetraplegia
and a C-sitting posture through posterior
stabilization of the pelvis in its most corrected posture; the fixed kyphosis can be
accommodated via back support shape and
angle.
It has been suggested that postural control
is the most important factor in preventing and
treating shoulder pain.144 Currently, the only
intervention available to address sitting posture is wheelchair modification guided by
individual therapists clinical experience and
the patients subjective comfort and preference.145148 Bolin et al.145 investigated how
sitting position and seating affected posture
and performance (balance, transfers, wheelchair skills, physical strain during wheelchair propulsion, spasticity, and respiration)
in four persons with C5 and C6 tetraplegia,
who received an adapted individualized intervention to reduce kyphosis and pelvic
obliquity. The individual adaptations were
reported to improve the persons sitting position and reduce or solve the specific problems mainly through providing erect sitting
posture and an increased upper body height.
The bucket seat (i.e., only tilting the seat
posteriorly) is thought to allow further reach
by its trunk supportive properties.146,149
Hastings et al.146 evaluated 14 subjects with
C6-T10 motor complete SCI in three manual
wheelchairs to determine whether postural
alignment and shoulder flexion range differed for persons with SCI seated in wheelchairs with standard configurations versus
those with posterior seat inclination and a
low backrest set perpendicular to the floor.
The wheelchair configuration with posterior

seat inclination and low backrest set perpendicular to the floor produced less shoulder
protraction, less head-forward position,
greater humeral flexion, greater vertical
reach above the seat plane, and less posterior
pelvic tilt than either conventional configurations. This alternate configuration produced more vertical postural alignment and
greater reach ability.
Propulsion and transfer techniques
Use long, smooth strokes that limit high

impacts on the pushrim. Allow the hand to
drift down naturally, keeping it below the
pushrim when not in actual contact with
that part of the wheelchair. Propulsion
technique is one aspect of wheelchair use that
is believed to be associated with upper limb
overuse injury. Long, smooth strokes maximize the contact time and impulse applied to
the handrim while minimizing the rapid rate
of loading and impacts (short duration, large
magnitude forces). Keeping the hand below
the pushrim when not in actual contact with
the pushrim would allow the shoulder to
relax in preparation for the next push cycle.
One aspect of propulsion technique is the
hand propulsion or stroke pattern determined
using the kinematic trajectory of the hand.
Several studies have identified that there are
three to five distinct stroke patterns wheelchair users adapt during propulsion.6668,116
Our pilot investigation also identified four
distinct patterns of propulsion used by participants with paraplegia and tetraplegia
(Figure 13).150 Although previous investigations suggested that a semicircular pattern,
where the hand dropped below the top of the
wheel in recovery, was the most efficient
because this pattern was associated with a
lower cadence,67 the arcing stroke patterns
109
those participants who display a semicircular

pattern than in those who have a single- or
double-loop pattern.150 Furthermore, participants with tetraplegia tended to utilize a
semicircular pattern during free propulsion
and an arcing pattern during fast and graded
propulsion, whereas participants with
paraplegia used a looping pattern during free
propulsion and an arcing or semicircle pattern during fast propulsion condition. The
direct relationship between hand trajectory
and development of shoulder pain, to our
knowledge, has not been investigated.
Figure 13. Four distinct patterns of propulsion

(stroke pattern) used by participants with
paraplegia and tetraplegia: double loop (DL),
Single loop (SL), semicircle (SC), and arc (A).
Reprinted, with permission, from Requejo P,
Bontrager E, Gronley JK, Newsam C, Mulroy
SJ, Perry J. The influence of stroke pattern on
shoulder kinetics during wheelchair propulsion. Paper presented at the Gait and Clinical
Movement Society Meeting: Gait & Posture;
2004; Lexington, KY.
were associated with greater mechanical efficiency.116 Richter et al. 68 examined the
stroke patterns in manual users with paraplegia pushing on a level and inclined surface
and determined that users adapt their stroke
patterns for pushing at different environmental conditions. They reported that none of the
participants used a semicircular pattern of
propulsion and that 73% of the participants
used an arcing pattern, particularly when
pushing uphill. We have identified that the
vertical shoulder joint forces are greater in
When performing transfers and weightrelief raises, make level transfers when possible. Avoid positions of impingement, and
vary the technique used and the arm that
leads. The mechanical loads on the shoulder during manual transfers and weightrelief raises have not been documented as
thoroughly as those during WCP. Manual
transfers both to and from a wheelchair and
depression raise maneuvers for pressure relief require the arms to lift nearly full body
weight. The trunk is elevated on the weightbearing arms, and the reaction force is transmitted vertically up to the shoulder. Bayley
et al.20 recorded intraarticular pressures in
the shoulder during transfers that exceeded
the arterial pressure by over 2.5 times. Only
the study performed by Harvey et al.52 utilized kinematics, kinetics, and EMG measures to evaluate the weight-relief maneuver in persons with C5 and C6 tetraplegia.
Despite the fact that they have received
scant attention in the literature, transfers
and weight-relief raises were identified as
common sources of shoulder pain complaints in persons with SCI.8,10 Wheelchair
transfers and weight-relief lifting present
110
the potential for both mechanical impingement and muscle overuse.

Allison et al.151 identified two movement
strategies when individuals performed lateral transfers. Some individuals performed
the lateral transfer using a rotator movement, where the head moves in opposite
direction to the pelvis. Others used a translational strategy, where the head and pelvis
move in concert. Three-dimensional elbow,
shoulder, head, and trunk kinematics during
posterior transfer on a level surface by persons with high-level SCI (C7 to T6) and
low-level SCI (T11 to L2) showed similar
patterns and magnitudes of the angular displacements between groups; persons with
high-level SCI initiated the task from a
forward-flexed posture, whereas those with
low-level SCI adopted an almost upright
alignment of the trunk.55 Harvey et al.52 in
examining the kinematics, reaction forces,
and net joint moments (expressed as internal muscle moments) during the upward
phase of a weight-relief maneuver from a
long seating position in persons with C5 and
C6 tetraplegia (N = 6), reported the increase
in the forces under the hand was associated
with an increase in the shoulder flexor and
adductor and elbow flexor moments. During the course of lifting, participants flexed
their shoulders and wrists and extended
their elbows. They generated peak shoulder
(0.65 Nm/kg) and elbow flexor (0.41 Nm/
kg) moments. Shoulder adductor moments
increased over the course of the lift. Persons with tetraplegia with no innervations
of the triceps elevate themselves by generating active shoulder flexor and adductor
moments.
When performing posterior transfers and
weight-relief raises, individuals with tetraplegia present different movement pat-
terns and muscular demands that may place

them at a greater risk for shoulder injury.
Persons with tetraplegia with no triceps innervations elevate themselves by generating active shoulder flexor and adductor
moments.52 Gagnon et al.55 in documenting
the kinematics and EMG during posterior
transfer on a level surface by persons with
high-level SCI (C7 to T6) compared to
those with low-level SCI (T11 to L2)
showed similar patterns and magnitudes of
the angular displacements between groups;
however, persons with high-level SCI initiated the task from a forward-flexed posture,
whereas those with low-level SCI adopted
an almost upright alignment of the trunk.
Higher muscular demands were seen for all
muscles in persons with high-level SCI during the transfer when compared to persons
with low-level SCI.55 Analysis of the movement patterns and muscular demands
placed on the shoulder during posterior
transfer to a level compared to elevated
surface also showed that high muscular demand developed when hands were positioned on the elevated surface.54
It is recommended that level transfers
should be performed when possible. Wang et
al.152 in evaluating nonimpaired individuals
reported that transfers to lower seat height
produced larger vertical ground reaction
forces and increased muscle activity in triceps brachii and posterior deltoid muscles to
overcome gravitational force. They also reported that transfers to higher seat height
resulted in a shift of the horizontal forces
from primarily anterior-posterior to mediallateral, requiring greater biceps brachii
muscle activities. They reported that transfers to an equal destination height required
less effort than transfers to both uneven
heights.
It is recommended that wheelchair users

vary the technique used and the arm that
leads. If there is weakness or pain in one arm,
this arm should be selected as the leading
arm.50,153 Intramuscular electrodes were used
to document and compare the intensity (percent MMT) of 12 shoulder muscles of the
trailing and leading arms of asymptotic participants (N = 12) with paraplegia while
transferring to and from a wheelchair (Figure 4).50 Moderate to high effort was recorded in several muscles of both the trailing
and leading limbs during the lift phase. In the
trailing arm, high level EMG was recorded
only in serratus anterior (54% MMT). Moderate activity was found in sternal pectoralis
major (49% MMT), infraspinatus (45%
MMT), anterior deltoid (44% MMT), supraspinatus (38% MMT), and latissimus
dorsi (25% MMT). In the leading arm, only
sternal pectoralis major demonstrated high
EMG intensity (81% MMT). Moderately
active muscles included serratus anterior
(47% MMT), latissimus dorsi (40% MMT),
infraspinatus (37% MMT), and long head of
biceps (28% MMT). The relative EMG intensities between the trailing compared to
leading arm showed that greater demands
were imposed on the trailing arm during
transfers. Forslund et al.153 used force plates
placed beneath the hand and buttocks to
evaluate the magnitude of forces during
transfer from table to wheelchair in participants with paraplegia (N = 13). The median
amplitude of the loading force (normalized
to percent body weight [%BW]) beneath the
trailing and leading arm was calculated from
the instant the hand touched the force plate
until the hand lifted off the force plate. For
both male and female participants evaluated,
the forces beneath the trailing hand were
greater than those in the leading hand.
111
Flexibility and resistance exercise
Incorporate flexibility exercises and resistance training into an overall adult fitness program. The training should be sufficient to maintain normal glenohumeral
motion and pectoral muscle mobility. The
training should be individualized and progressive, should be of sufficient intensity to
enhance strength and muscular endurance, and should provide stimulus to exercise all the major muscle groups to painfree fatigue. For persons with paraplegia
who have neurologically intact shoulder
musculature, programs for management of
shoulder pain are quite similar to programs
designed for persons without disability.
These programs most often include rotator
cuff strengthening, steroid injections, and
modalities as indicated.154157 For persons
with SCI, however, exercise programs for
management of shoulder pain should include
training of the larger thoracohumeral musculature in non-weight-bearing positions.28,29 In addition, stretching of the anterior structures of the shoulder joint is
recommended for individuals with SCI to
counter the internally rotated posture of
the shoulder that develops secondary to
tightness in the anterior capsule and the
sternal pectoralis major. For improved
program adherence, exercise programs for
persons with paraplegia should be performed
from the wheelchair, which may require
modification of the exercise setup. For persons with tetraplegia, shoulder exercise programs require a unique design as their
injury level may limit the amount of shoulder musculature available to strengthen. In
addition, impaired grasp function in persons with tetraplegia requires additional
exercise modification for complete inde-
112
pendence (e.g., wrist weights take the

place of dumbbells and loops take the place
of handles). Impaired balance may necessitate the use of chest straps and posturing
devices attached to the backrest to maintain appropriate balance.
Three studies have investigated the impact
of an exercise program on shoulder pain in
individuals with SCI.158160 Two of the three
studies reported a statistically significant decline in shoulder pain with the intervention.159,160 In the study by Nash et al.,159 exercises including rows, military presses, curls,
and dips were performed using a multistation
exercise system. Despite the fact that the exercises were not specifically designed to impact
shoulder pain, scores on the WUSPI for the
seven participants declined from 31.9 to 5.7
(out of 150 maximum possible score) at the
end of the 16-week exercise program.
Nawoczenski et al.160 tested an 8-week
home exercise program of stretching for both
the anterior and posterior shoulder and
strengthening of scapular muscles and the
shoulder external rotator muscle groups with
elastic bands. Participants in the intervention
group demonstrated a statistically significant
reduction in shoulder pain scores (from 43 to
21 on the WUSPI) compared to participants
in the control group who had little change in
pain (from 2 to 4 on the WUSPI). Participants
in the control group were younger than in the
intervention group and were asymptomatic
for shoulder pain at entry into the study.
In contrast, Curtis et al.158 reported equivocal results with a 6-month home-based exercise program that was specifically designed
to reduce shoulder pain in individuals with
SCI. The program included stretching of the
anterior shoulder and strengthening exercises for the shoulder external rotator, adductor, and scapular retractor muscle groups.
WUSPI scores decreased modestly in the
intervention group (23.3 to 13.2), but the
difference in shoulder pain reduction seen in
the intervention and control groups was not
statistically significant. This is likely due to
the mild levels of shoulder pain present in
both groups, as only 50% of participants in
either group had shoulder pain at the time of
the study. No study as yet has examined the
effectiveness of an exercise intervention in
reducing shoulder pain in individuals with
SCI using a randomized clinical trial nor has
any study investigated the efficacy of a preventive exercise program.
Conclusion
Research on quantification of shoulder
joint loading and muscular demands during
WCP, self-transfers, weight-relief raises,
and overhead activities has led to development of recommendations designed to reduce shoulder joint loading and muscular
demands and to increase the shoulders capacity to handle the loads during manual
wheelchair activities. Future work linking
the mechanical loads, long-term exposure,
and the effects of preventive measures aimed
at preserving shoulder function in the manual
wheelchair user with SCI is still needed.
Acknowledgments
This research was supported by a National
Institute on Disability and Rehabilitation
Research grant H133E020732.
113
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Evidence-Based Strategies to Preserve

Shoulder Function in Manual

he increased demand on the upper

and muscular demands and to increase the

Philip S. Requejo, PhD, is Research Engineer,

Amigos National Rehabilitation Center, Downey,

JoAnne K. Gronley, DPT, is Associate Director of

Strategies to Preserve Shoulder Function

tion of approximately 253,000 persons now

with specific ADLs.16 Work or school was the

TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 2008

shoulder pathology to chronic overuse of

that displace the humeral head upward from

Strategies to Preserve Shoulder Function

functionally equivalent to sustaining a higher

TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 2008

Strategies to Preserve Shoulder Function

and ergometers (Figure 6). These setups

TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 2008

Strategies to Preserve Shoulder Function

monitoring devices that use miniaturized

Simultaneous recording of muscle activity

TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 2008

was recorded in the sternal pectoralis major

loss of sternal pectoralis major function

Strategies to Preserve Shoulder Function

activity (31% to 81% maximum) during

Figure 7. (A and B) Two consecutive cycles of

Determining the force impact during WCP

TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 2008

wheels68,7779 or an ergometer80 to accurately

forces was performed by Veeger et al.102 and

Early studies on WCP documented that

Evaluation of the mechanical loads during

Strategies to Preserve Shoulder Function

laboratory and in the home and community.

TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 2008

Figure 8. Mean vertical shoulder net joint

Strategies to Preserve Shoulder Function

groups. Participants who later developed

TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 2008

Individuals with SCI should avoid extreme

Figure 9. Use of a transfer board as a means to

Minimize extreme or potentially injurious positions at the shoulder by avoiding

Strategies to Preserve Shoulder Function

these kinematic variables may be an adaptive

TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 2008

avoiding strenuous environmental barriers

Recommend a high-strength, fully

Strategies to Preserve Shoulder Function

with tetraplegia, particularly at the C6 level,

Inc., Oakdale, PA) and Quickie Xtender

TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 2008

Figure 11. Electromyographic (EMG) activity

self-selected free and fast speeds and then up

shoulder muscle activity compared to propulsion in the standard wheelchair (Figure

Strategies to Preserve Shoulder Function

well as orthotic transfer devices that reduce

Adjust the rear axle as far forward as

possible without compromising the stability

TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 2008

Figure 12. Illustration of the difference in push

position (axle moved forward) reduces the