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Medicine and Health

How to prevent Hand/Shoulder overused injury for manual wheelchair users

For manual wheelchair users, there is always a potential risk for shoulder pain and injury due to overuse, which may worsen over the long term for some individuals (Jain et.al, 2010). For patients with spinal cord injury, this risk is often substantial, with up to 70 percent of all patients sustaining this type of injury, creating additional complications (Jain et.al, 2010). For wheelchair athletes, shoulder pain is typically caused by a weakening of the rotator cuff and nearby adductors (Tadlock, 2009). In addition to shoulder pain, many wheelchair users experience wrist, elbow, and hand pain, with some users requiring pain medication or other alleviators to reduce this pain (Cooper et.al, 1998). It is necessary to evaluate why shoulder pain persists in many manual wheelchair and what steps might be taken to overcome this pain in this population group.

In some emergency departments, approximately 100,000 injuries associated with wheelchairs are reported on an annual basis (Xiang et.al, 2006). For this group of wheelchair users, 65-80 percent of these injuries were associated with tips and falls, with injuries taking place in a variety of areas, including homes and hospitals for adult users and public locations for children (Xiang et.al, 2006). One of the issues to consider with wheelchair injuries is poor biomechanics, which may be adjusted to reduce the risk of recurrent injuries in some individuals (Tadlock, 2009). In addition, many wheelchair users experience pain as a result of the necessity to perform activities of daily living in a routine manner, which typically uses the same muscle groups repeatedly (McClintock, 2013). In addition, some wheelchair users commonly experience pressure sores because they are required to remain in the same position for long periods of time (McClintock, 2013). In each of these examples, proper alleviation of symptoms must be achieved in order to promote healthier outcomes and improved management of the wheelchair state within this population group.

Due to the risks associated with manual wheelchairs for some users, it is important to address suitable alternatives. In prior decades, the crank and level propulsion alternatives were used to alleviate some of the pain and other risks associated with manual wheelchairs (van der Woude et.al, 2001). However, more recently, advancements in these original crank and level propulsion systems emerged and provided increased speed and endurance for wheelchair users (van der Woude et.al, 2001). These systems are beneficial as follows: “crank and lever systems allow natural forms of both synchronic and asynchronic arm use, as well as one-arm use. The common use of gear systems allows wheelchair propulsion under various environmental conditions (steep slopes, rough terrain) and for different user groups” (van der Woude et.al, 2001, p. 767). In addition, arm-crank propulsion has become an increasingly popular alternative in the industry to improve output and endurance (van der Woude et.al, 2001). It is believed that this type of propulsion mechanism serves to reduce the overuse of arm and shoulder muscles that typically fatigue quickly with traditional wheelchair use (van der Woude et.al, 2001). These efforts are important indicators of the technological advancements of wheelchairs to alleviate problems and pain in many users. It is important to address all forms of physical strain associated with wheelchair use and to take the steps that are necessary to achieve improved mobility without pain or pressure (van der Woude et.al, 2001). It is likely that wheelchair users will experience greater comfort with whichever design they choose by becoming trained in how to use their wheelchairs more appropriately and effectively to reduce injury (van der Woude et.al, 2001). The level of mobility achieved by wheelchair users is likely to be improved by the correct type of equipment, which should be identified in accordance with individual circumstances (van der Woude et.al, 2001).

Advancements in wheelchair design represent a means of reducing the strains and other problems associated with traditional wheelchair use. Fiola and Staats demonstrate that the proper selection of a wheelchair requires significant thought and analysis in order to select the chair that will provide the best possible experience for the user. It is important to begin the process with seating the individual so the maximum level of comfort is achieved, including a neutral pelvis, natural curvature of the spine, a balanced head position, and loaded legs and feet (Fiola and Staats). In addition, seating must allow the individual to move about as needed, and to feel a sense of safety within the chair itself (Fiola and Staats).

When selecting the proper chair, the client should be observed with respect to his or her level of mobility and how transfers in and out of the existing chair are achieved (Fiola and Staats). The pelvis should be aligned properly but also allow for movement to one side or another if needed, and the trunk should follow suit (Fiola and Staats). The wheelchair frame should be lightweight yet durable and the seat cushion should be comfortable and allow pressure to be evenly distributed to avoid complications such as pressure sores (Fiola and Staats). The backrest should allow the trunk to sit properly upright and minimize slouching and the armrests might not be necessary for some users when they possess higher mobility (Fiola and Staats). Tires should be pneumatic and casters should be larger to promote improved resistance (Fiola and Staats). Also, the dimensions of the chair should be appropriate from all angles to provide maximum comfort and mobility for the user under all conditions and seat height should be consistent with individual measurements to prevent any risk of falls, tips, or exhaustive movements from the arms and shoulders (Fiola and Staats). These tools provide users with the best possible type of wheelchair to meet their specific needs and to accommodate their health concerns (Fiola and Staats).

The prevention of injury is a critical component when training wheelchair users how to manage this type of equipment. For manual wheelchair users, alleviating the use of the shoulder depressors is critical in preventing injury to this area (University of Washington, 2013). If the rotator cuff is overused, it may become damaged, thereby making it difficult for wheelchair users to lift the arms and move them to the side as needed (University of Washington, 2013). These users must compensate by using other techniques that remove some of the pressure from the shoulder muscles (University of Washington, 2013).

Elbow and wrist injuries are also common due to overuse with wheelchairs, and for the elbow, the extension of the wrist often leads to elbow pain and discomfort (University of Washington, 2013). To alleviate these symptoms, it is recommended “to reduce weight bearing in a straight-armed position with the hand bent back (this often occurs during transfers)” (University of Washington, 2013). This practice serves as a compensatory technique to overcome the strain associated with repetitive movements with regular whee lchair use (University of Washington, 2013).  Furthermore, Carpal Tunnel Syndrome has become increasingly common with this group due to extending or flexing the wrist repeatedly, which causes damage to the median nerve and requires a change in position of the wrist so that the pressure of the same movement is alleviated as best as possible (University of Washington, 2013).

Finally, to improve any symptoms related to muscle overuse with the routine use of a wheelchair, it is necessary to establish a balance between muscle use, including those in the shoulders, wrists, and elbows in an effort to reduce injury (University of Washington, 2013). These techniques will support the improvement of muscles that would otherwise be overused due to repetitive movements (University of Washington, 2013).

References

Cooper, R.A., Boninger, M.L., and Robertson, R.N. (1998). Heavy handed: repetitive strain injury among manual wheelchair users. Team Rehab Report, 35-38.

Fiola, K., and Staats, Z. Manual wheelchair seating and mobility: preserving the upper limb and  promoting function throughout the life span. TIRR Memorial Hermann Rehabilitation & Research. Power Point Presentation.

Jain, N.B., Higgins, L.D., Katz, J.N., and Garshick, E. (2010). Association of shoulder pain with the use of mobility devices in persons with chronic spinal cord injury. PM&R, 2(10), 896-900.

McClintock, P.M. (2013). Introduction to common overuse injuries in wheelchair users. Retrieved from http://www.ncpad.org/96/707/Overuse~Injuries~in~Wheelchair~Users

Stadlock, T. (2009). Reducing injury in wheelchair athletes. Retrieved from http://www.thomastadlock.com/index.cfm?action=viewarticle&action2=21

University of Washington (2013). Prevention of overuse injuries. Retrieved from http://sci.washington.edu/info/forums/reports/prevention_injuries.asp

van der Woude, LHV, Dallmejier, AJ, and Janssen, TWJ (2001). Alternative modes of manual wheelchair ambulation. American Journal of Physical Medicine & Rehabilitation, 80(10),  765-777.

Xiang, H., Chany, A.M., and Smith, G.A. (2006). Wheelchair related injuries treated in US  emergency departments. Injury Prevention, 12(1), 8-11.