Key Points
The evidence suggests that stroke pattern use varies based on individual preference and the environmental demands with some stroke patterns being more effective to achieve specific outcomes.
The evidence supports that to avoid accumulating shoulder impingement stresses proper propulsion technique must be considered based on a combination of kinematics (e.g., contact angle, stroke frequency, movement patterns at each joint), stroke pattern, wheelchair fit and set up.
Neck, trunk, scapular, clavicle, elbow, wrist and shoulder kinetics and kinematics singly or cumulatively influence the efficacy of manual wheelchair propulsion and therefore all should be considered in propulsion efficiency as well as in propulsion-related injuries, particularly if propulsion speed or surface slope increases.
The push and recovery phases of propulsion both need to be considered in relation to manual wheelchair propulsion as the kinetics and kinematics differ, and differ between people with paraplegia and tetraplegia, which therefore have implications for propulsion training in the clinical setting.
The following need to be considered in relation to propulsion and back support height; a) effect on propulsion cadence; b) amount of shoulder range of motion used and; c) the length of the push stroke (i.e., length between the start and end position of the hand on the rim).
Wheelchair seating characteristics, such as back support height and seat dump angle, affect body positioning and kinematics of propulsion. Therefore, wheelchair and seating set-up both need to be considered when evaluating kinetics and kinematics of wheelchair.
Wheeling cross slope can negatively affect the cadence and power that is required for wheelchair propulsion.
The strength of specific shoulder and elbow muscles, and the ability to flex the trunk forward all affect the efficiency in performing advanced wheelchair skills particularly those associated with wheelies and caster pop-ups. Given the increased mechanical and muscular demands in these types of advanced skills, the quality of shoulder, elbow and trunk movements should be considered to balance protection of the upper extremity shoulder with being functional in the community.
Manual wheelchairs with adjustable axle position appear to improve wheelchair propulsion and reduce the risk of upper extremity injury.
The use of lighter weight wheelchairs may improve propulsion efficiency in those with SCI particularly at the start of propulsion.
Body weight management is important in reducing the forces required to propel a wheelchair and reducing the risk of upper extremity injury.
There is insufficient evidence to determine if wheelchair frame type or wheel type are more effective in reducing spasticity by absorbing vibration forces when wheeling.
There is limited evidence to suggest that tires with less than 50% inflation can cause an increase in energy expenditure.
Use of flexible handrims may reduce upper extremity strain thereby reducing discomfort and pain symptoms during wheelchair propulsion.
The use of power-activated power-assist wheelchairs (PAPAW) provide manual wheelchair users with paraplegia and tetraplegia with a less strenuous means of mobility, improve functional capabilities and reduce the risk of upper extremity injury.
Propulsion characteristics of contact angle, stroke frequency and peak force at the handrim, all noted to be important to maintaining upper extremity health during propulsion, can be positively affected through w/c propulsion training.
Clinicians should consider incorporating a multimedia approach, such as video and verbal instruction with observational feedback, into wheelchair propulsion training particularly for people who are new to w/c use.
Physical conditioning and strengthening of the upper extremity are important to the development of wheelchair propulsion capacity; it should begin at initial rehabilitation.
Increased risk of developing or exacerbating shoulder pain is an essential consideration in all wheelchair propulsion training programs at initiation and for ongoing training.
Wheelchair use varies between individuals, however daily propulsion distance is small amongst most users. Shoulder strength, the user’s environment, and age all contribute to varaitions and limitations in propulsion distance amongst wheelchair users particularly in the community; these factors should be considered when developing rehabilitation plans related to mobility.
Many of the predictive risk factors for wheelchair related falls and resultant injuries are modifiable; therefore, considerations and education related to preventing falls should be included in wheelchair interventions.
Maintenance and repair issues arise frequently for people who use wheelchairs therefore are important considerations in the wheelchair service delivery process and the manufacturing process.
Optimizing the potential for satisfaction with wheelchair use requires consideration of the fit and function of the wheelchair during the service delivery process particularly for quality of life-based activities such as leisure pursuits; satisfaction with the service delivery process requires timeliness throughout the wheelchair provision process.
There is good evidence that wheelchair skill training can improve skills in the short term and that video feedback produces similar results as conventional skill training.
There is strong evidence that manual wheelchair skills training causes an immediate improvement in wheelchair skills, but is mixed evidence regarding how well skills learned are retained.
When learning to perform wheelies improvements in postural stability are noted when the rolling resistance is increased.
The focus of wheelchair skills training during shortening rehabilitation stays should consider the person’s home and community environments and activities is needed as it is suggested that not all skills are essential to functioning in daily life.
Considerations for how individuals use power wheelchairs should include more than distance and speed travelled, as most people spend little time travelling any distance compared to the amount of time they spend in their power wheelchair.
For the SCI population power wheelchair provision needs to include at a minimum customizable programmable control.
Consideration should be given to the potential provision of both power and manual wheelchairs to meet basic living needs for the SCI population.
Patterns of use for power positioning devices are variable but typically in small ranges of amplitude, with the primary reasons for use being discomfort and rest.
Individual attention to spinal/pelvic posture and positioning for SCI clients is essential for appropriate wheelchair prescription and set-up.
Use of lateral trunk supports in specialized seating improve spinal alignment, reduce lumbar angles and reduce muscular effort for postural control.
The set up and type of seating and wheelchair frame are critical to supporting the person’s postural stability thereby effecting functional ability to reach and engage in pressure management strategies.
No one cushion is suitable for all individuals with SCI.
Cushion selection should be based on a combination of pressure mapping results, clinical knowledge of prescriber, individual characteristics, tissue loading response and preference.
More research is needed to see if decreasing ischial pressures or decreasing risk factors such as skin temperature via the use of specialty cushions will reduce pressure injury risk
Pressure mapping is a useful tool for comparing pressure redistribution characteristics of cushions for an individual, but it needs to be a part of the full evaluation not the main part or only evaluation; further research is needed to explore the relationship with tissue deformation.
Contoured foam cushions compared to flat foam cushions seem to provide a seat interface that reduces the damaging effects of external loading and tissue damage.
Peak interface pressure is greater for dynamic movement in SCI subjects than static sitting but cumulative loading is comparable between dynamic and static loading for the SCI population.
Peak pressures appear to be located slightly anterior to the ischial tuberosities (IT).
The use and integration of forward reaching into daily life activities can be used as a means to promote regular pressure redistribution. Caution however is needed to ensure the movement is of adequate distance and duration to affect pressure management.
Leaning forward at least 45° (elbows on knees position) or lateral trunk leaning to 15° reduces pressure and increases blood flow and tissue oxygenation at the sitting surface; it is important to be able to return to the original upright sitting position.
For most individuals with SCI, the use of a push-up/vertical lift is unlikely to be of sufficient duration to be beneficial for managing sitting pressure and has potential to contribute to repetitive strain injuries and a reduction of subacromial space.
The back support plays an important role in pressure management on the sitting surface.
Backrest recline alone to 120° decreased average maximum pressures in the ischial tuberosity area but also causes the greatest ischial tuberosity shift (up to 6 cm). Further research on the effect of friction/shear on the sitting surface in relation to the ischial tuberosity shift is required to determine if there is benefit in using backrest recline alone.
There is an inverse relationship between tilt angle and pressure at the sitting surface. Significant pressure redistribution realized was variable by person but on average started around 30° of tilt with maximum tilt providing maximum pressure redistribution.
It cannot be assumed that a change in interface pressure through use of tilt/recline equates to an increase in blood flow at the ischial tuberosities (IT).
The variability in blood flow and interface pressure changes associated with tilt/recline, supports the need for an individualized approach to education around power positioning device use for pressure management.
The type and duration of position changes for pressure management must be individualized.
More research is needed to determine the parameters of position changes in relation to interface pressure and blood flow at the sitting surface tissues to help prevent pressure ulcers post SCI.
While power positioning technology including combinations of tilt, recline and stand, offer many health-related benefits, individualized assessment and thorough consideration of contraindications are required to ensure safe and appropriate use.
To mobilize knowledge related to pressure, and muscle/skin perfusion into clinical practice further research is needed to determine: 1) the influence of cushion type on muscle and skin perfusion; 2) the effects of friction and shear on skin and muscle perfusion and pressure during use of recline and/or tilt and/or standing; 3) the influence of postural deformities/tendencies on perfusion levels on both of the above and; 4) the effects of duration of large amplitudes of position changes within participants’ regular daily routines of position changes.
There is lower level evidence to suggest that people who receive specialized seating assessment and/or client-centred wheelchair interventions have better outcomes.
