Lisa Lighthall Haubert

Strengthening and Optimal Movements for Painful Shoulders (STOMPS) in Chronic Spinal Cord Injury: A Randomized Controlled Trial

Background Shoulder pain is a common problem after spinal cord injury (SCI), with negative effects on daily activities and quality of life (QOL). Objective The purpose of this study was to determine the effect of an exercise program and instruction to optimize performance of upper-extremity tasks on shoulder pain in people with paraplegia from SCI. Methods/Design Eighty individuals with paraplegia from SCI and shoulder pain were randomly assigned to receive either an exercise/movement optimization intervention or an attention control intervention. The exercise/movement optimization intervention consisted of a 12-week home-based program of shoulder strengthening and stretching exercises, along with recommendations on how to optimize the movement technique of transfers, raises, and wheelchair propulsion. The attention control group viewed a 1-hour educational video. Outcome measures of shoulder pain, muscle strength (force-generating capacity), activity, and QOL were assessed at baseline, immediately after intervention, and 4 weeks later. Results Shoulder pain, as measured with the Wheelchair Users Shoulder Pain Index, decreased to one third of baseline levels after the intervention in the exercise/movement optimization group, but remained unchanged in the attention control group. Shoulder torques, most 36-Item Short-Form Health Survey questionnaire (SF-36) subscale scores, and QOL scores also were improved in the exercise/movement optimization group, but not in the attention control group. Improvements were maintained at the 4-week follow-up assessment. Limitations Many of the outcome measures were self-reported, and the participant dropout rate was high in both groups. Additional studies are needed to determine whether the results of this study can be generalized to individuals with tetraplegia. Conclusions This home-based intervention was effective in reducing long-standing shoulder pain in people with SCI. The reduction in pain was associated with improvements in muscle strength and health-related and overall QOL.

Effect of fore-aft seat position on shoulder demands during wheelchair propulsion: part 1. A kinetic analysis.

Abstract Background/Objective: The highly repetitive and weight-bearing nature of wheelchair (WC) propulsion has been associated with shoulder pain among persons with spinal cord injury (SCI). Manipulation of WCseat position is believed to reduce the overall demand of WC propulsion. The objective of this investigation was to document the effect offore-aft seat position on shoulder joint kinetics. Methods: Thirteen men with complete motor paraplegia propelled a test WC in 2 fore-aft seat positions during free, fast, and graded conditions. The seat-anterior position aligned the glenohumeral joint with the wheel axle and the seat-posterior position moved the glenohumeral joint 8 cm posteriorly. The right wheelof the test chair was instrumented to measure forces applied to the pushrim. An inverse dynamics algorithm was applied to calculate shoulder joint forces, external moments, and powers. Results: 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 freeand fast propulsion. During graded propulsion, the seat-posterior position displayed increased internal rotation moment, decreased sagittal plane power absorption, and increasedtransverseplane power generation. Conclusions: This investigation provides objective support that a posterior seat position reduces the superior component of the shoulder joint resultant force. Consequently, this intervention potentially diminishes the risk for impingement of subacromial structures.

Shoulder muscular demand during lever-activated vs pushrim wheelchair propulsion in persons with spinal cord injury.

Abstract Background/Objective: The high demand on the upper limbs during manual wheelchair (WC) use contributes to a high prevalence of shoulder pathology in people with spinal cord injury (SCI). Leveractivated (LEVER) WCs have been presented as a less demanding alternative mode of manual WC propulsion. The objective of this study was to evaluate the shoulder muscle electromyographic activity and propulsion characteristics in manual WC users with SCI propelling a standard pushrim (ST) and LEVER WC design. Methods: Twenty men with complete injuries (ASIA A or B) and tetraplegia (C6, n = 5; C7, n = 7) or paraplegia (n = 8) secondary to SCI propelled STand LEVER WCs at 3 propulsion conditions on a stationary ergometer: self-selected free, self-selected fast, and simulated graded resistance. Average velocity, cycle distance, and cadence; median and peak electromyographic intensity; and duration of electromyography of anterior deltoid, pectoralis major, supraspinatus, and infraspinatus muscles were compared between LEVER and ST WC propulsion . Results: Sign ificant decreases in pectoralis major and supraspinatus activity were recorded during LEVER compared with ST WC propulsion. However, anterior deltoid and infraspinatus intensities tended to increase during LEVER WC propulsion. Participants with tetraplegia had similar or greater anterior deltoid, pectoralis major, and infraspinatus activity for both ST and LEVER WC propulsion compared with the men with paraplegia. Conclusions: Use of the LEVER WC reduced and shifted the shoulder muscular demands in individuals with paraplegia and tetraplegia. Further studies are needed to determine the impact of LEVER WC propulsion on long-term shoulder function.

Comparison of Energy Expenditure and Propulsion Characteristics in a Standard and Three Pushrim-Activated Power- Assisted Wheelchairs

Background: Pushrim-activated power-assisted wheelchairs (PAPAWs) reduce the demands of manual wheelchair (WC) propulsion by providing additional force with release of the pushrim. Method: This study compared energy expenditure and propulsion characteristics in individuals with spinal cord injury propelling their own WCs and three commercially available PAPAWs. We hypothesized that PAPAWs would reduce energy expenditure and enhance propulsion characteristics, depending upon the delivery of power-assistance and user ability. Results: PAPAWs reduced the rate of oxygen consumption for most participants; however, the PAPAW that maximized self-selected propulsion velocity and minimized oxygen cost varied. Conclusion: Results of this study would benefit individuals considering use of a PAPAW.

Shoulder Strength and Physical Activity Predictors of Shoulder Pain in People With Paraplegia From Spinal Injury: Prospective Cohort Study

Background Shoulder joint pain is a frequent secondary complaint for people following spinal cord injury (SCI). Objective The purpose of this study was to determine predictors of shoulder joint pain in people with paraplegia. Methods/Design A 3-year longitudinal study was conducted. Participants were people with paraplegia who used a manual wheelchair for at least 50% of their mobility and were asymptomatic for shoulder pain at study entry. Participants were classified as having developed shoulder pain if they experienced an increase of ≥10 points on the Wheelchair Users Shoulder Pain Index in the 3-year follow-up period. Measurements of maximal isometric shoulder torques were collected at study entry (baseline), 18 months, and 3 years. Daily activity was measured using a wheelchair odometer, and self-reported daily transfer and raise frequency data were collected by telephone every 6 weeks. Results Two hundred twenty-three participants were enrolled in the study; 39.8% developed shoulder pain over the 3-year follow-up period. Demographic variables and higher activity levels were not associated with shoulder pain onset. Baseline maximal isometric torque (normalized by body weight) in all shoulder muscle groups was 10% to 15% lower in participants who developed shoulder pain compared with those who remained pain-free. Lower shoulder adduction torque was a significant predictor of shoulder pain development (log-likelihood test=11.38), but the model explained only 7.5% of shoulder pain onset and consequently is of limited clinical utility. Limitations Time since SCI varied widely among participants, and transfer and raise activity was measured by participant recall. Conclusions Participants who developed shoulder pain had decreased muscle strength, particularly in the shoulder adductors, and lower levels of physical activity prior to the onset of shoulder pain. Neither factor was a strong predictor of shoulder pain onset.

Skyfarer: Design Case Study of a Mixed Reality Rehabilitation Video Game

This paper outlines a design case study for Skyfarer, a mixed reality rehabilitation application developed for upper body exercise of individuals aging with disability. We describe how experience, experiential and participatory design methodologies were combined to develop a game, which was publicly exhibited at IEEE VR and ACM SIGGRAPH, and formally evaluated in a biomechanical study at Rancho Los Amigos National Rehabilitation Center RLANRC.

Body mass index changes over 3 years and effect of obesity on community mobility for persons with chronic spinal cord injury

Objective: To identify the prevalence of obesity in persons with chronic spinal cord injury (SCI), determine change in body mass index (BMI) over time, and identify impact of obesity on community mobility. Design: Prospective three year longitudinal study. Setting: Outpatient clinic of rehabilitation center. Participants: Convenience sample of 222 persons with paraplegia between 2–20 years post SCI. Outcome Measures: BMI at baseline and three years; community mobility (daily wheelchair propulsion distance and velocity, average number of daily transfers and depression raises). Results: Participants were 34.1 (27.3, 40.3) years of age and median duration of SCI was 8.7 (3.2, 15.1) years. The SCI adjusted BMI classification identified 44% of participants as obese. BMI increased over time with 13% moving into a higher weight category. Median change in BMI was 0.46 (−0.92, 1.50) kg/m2 (z = −2.684, P = 0.007), and increased at a rate of 0.15 kg/m2/yr. Average BMI was negatively correlated with daily wheelchair propulsion distance (r = −0.179, P = 0.009), however there was no significant relationship with velocity, number of daily transfers or depression raises. Conclusion: The majority of participants with chronic SCI were overweight (23%) or obese (44%) and BMI increased by 0.46 kg/m2 over three years. Those with higher BMIs pushed their wheelchairs shorter distances, but other mobility measures were not impacted by body weight. Continued mobility activities with increasing body weight can increase risk for shoulder injury. Identifying persons who are obese allows for directed and timely health and mobility intervention.

Car Transfer and Wheelchair Loading Techniques in Independent Drivers with Paraplegia

Car transfers and wheelchair (WC) loading are crucial for independent community participation in persons with complete paraplegia from spinal cord injury, but are complex, physically demanding, and known to provoke shoulder pain. This study aimed to describe techniques and factors influencing car transfer and WC loading for individuals with paraplegia driving their own vehicles and using their personal WCs. Sedans were the most common vehicle driven (59%). Just over half (52%) of drivers place their right leg only into the vehicle prior to transfer. Overall, the leading hand was most frequently placed on the driver’s seat (66%) prior to transfer and the trailing hand was most often place on the WC seat (48%). Vehicle height influenced leading hand placement but not leg placement such that drivers of higher profile vehicles were more likely to place their hand on the driver’s seat than those who drove sedans. Body lift time was negatively correlated with level of injury and age and positively correlated with vehicle height and shoulder abduction strength. Drivers who transferred with their leading hand on the steering wheel had significantly higher levels of shoulder pain than those who placed their hand on the driver’s seat or overhead. The majority of participants used both hands (62%) to load their WC frame, and overall, most loaded their frame into the back (62%) vs. the front seat. Sedan drivers were more likely to load their frame into the front seat than drivers of higher profile vehicles (53 vs. 17%). Average time to load the WC frame (10.7 s) was 20% of the total WC loading time and was not related to shoulder strength, frame weight, or demographic characteristics. Those who loaded their WC frame into the back seat had significantly weaker right shoulder internal rotators. Understanding car transfers and WC loading in independent drivers is crucial to prevent shoulder pain and injury and preserve community participation.

Relationship Between Hand Contact Angle and Shoulder Loading During Manual Wheelchair Propulsion by Individuals with Paraplegia

BACKGROUND Shoulder loading during manual wheelchair propulsion (WCP) contributes to the development of shoulder pain in individuals with spinal cord injury (SCI). OBJECTIVE To use regression analysis to investigate the relationships between the hand contact angle (location of the hand on the pushrim at initial contact and release during the push phase of the WCP cycle) with propulsion characteristics, pushrim forces, and shoulder kinetics during WCP in individuals with paraplegia. METHODS Biomechanical data were collected from 222 individuals (198 men and 24 women) with paraplegia from SCI during WCP on a stationary ergometer at a self-selected speed. The average age of participants was 34.7 years (±9.3), mean time since SCI was 9.3 years (±6.1), and average body weight was 74.4 kg (±15.9). The majority (n = 127; 56%) of participants had lower level paraplegia (T8 to L5) and 95 (42%) had high paraplegia (T2 to T7). RESULTS Increased push arc (mean = 75.3°) was associated with greater velocity (R = 0.384, P < .001) and cycle distance (R = 0.658, P < .001) and reduced cadence (R = -0.419, P <.001). Initial contact angle and hand release angles were equally associated with cycle distance and cadence, whereas a more anterior release angle was associated with greater velocity (R = 0.372, P < .001). When controlling for body weight, a more posterior initial contact angle was associated with greater posterior shoulder net joint force (R = 0.229, P = .001) and greater flexor net joint moment (R = 0.204, P = .002), whereas a more anterior hand release angle was significantly associated with increased vertical (R = 0.270, P < .001) and greater lateral (R = .293, P < .001) pushrim forces; greater shoulder net joint forces in all 3 planes - posterior (R = 0.164, P = .015), superior (R = 0.176, P = .009), and medial (R = 0.284, P < .001); and greater external rotator (R = 0.176, P = .009) and adductor (R = 0.259, P = .001) net joint moments. CONCLUSIONS Current clinical practice guidelines recommend using long, smooth strokes during manual WCP to reduce peak shoulder forces and to prevent shoulder pain development. The position of the hand at both initial contact and hand release must be considered in WCP training. It is recommended that participants should reach back to initiate contact with the pushrim to maximize push arc but avoid a more anterior hand position at release, because this could increase shoulder load during the push phase of WCP.