ATP Series

Shouldering an Enormous Load

Preserving the Shoulder Health of Wheelchair Self-Propellers

The statistics vary from report to report according to which group of consumers is questioned, but regardless, the answers are sobering. Out of every 10 manual wheelchair users who are asked, three to seven will report having shoulder pain sometime during their lives.*

* Entities reporting or citing those statistics include the University of Illinois at Urbana-Champaign’s Office of Technology Management; the Journal of Rehabilitation Research & Development, Vol. 41, No. 38, and Vol. 42, No. 3; and the Journal of Spinal Cord Medicine 2005; 28(5), U.S. National Library of Medicine, National Institutes of Health.

That’s especially significant because manual wheelchair users depend on their shoulders to accomplish so much, from propulsion to transfers to push-ups for pressure relief. And that’s in addition to everyday reaching, lifting and carrying that can also be magnified by less-than-ideally-accessible environments.

A shoulder injury or shoulder pain that would be a nuisance to a non-wheelchair user can have a debilitating impact on the mobility and independence of consumers who use manual wheelchairs — making shoulder health a critical topic for them and the healthcare professionals who support them.

What Factors Make the Difference?

“I see the three primary contributing factors to shoulder preservation from wheelchair use as transfers, propelling and stopping, and activities of daily living (ADLs),” says Alan Ludovici, senior product design engineer for Ki Mobility.

Ludovici speaks from personal experience. A complex rehab industry veteran who’s been instrumental in the design and creation of many ultralightweight chairs, he’s also a veteran ultralight user himself.

“Toileting, work environment, cleaning, cooking, etc., in your chair configuration affects how you use your upper body, which results in the amount of stress on your shoulders,” he explains.

Shoulder HealthAsked about how an ultralight chair can be configured to support and preserve shoulder health, Ludovici started by considering the many transfers a manual wheelchair user performs in a typical day.

“It is important to consider optimizing the chair for transfers by closing the gap between the front of the chair and the transfer destination, as well as matching seat heights and angles to surfaces,” Ludovici says. “It is equally as important to pay special attention to transfer conflicts such as wheels, the distance/time from the chair to car, bed, toilet, etc.”

Ludovici also suggests that observing the way a wheelchair client performs his/her transfers can help to identify other difficulties.

“Lastly, look at how the individual transfers and what is most appropriate,” he says. “[For example], it is difficult getting around the rear wheel when using the slide lateral transfer technique. All of these considerations can impact the biomechanics and reduce shoulder strain.”

Regarding propelling and stopping an ultralight chair, Ludovici says, “It really has to do with optimal wheel access from a biomechanics standpoint to facilitate the most efficient stroke. The ‘deeper’ you are in the wheel, the more upper shoulder strength you use. A wheel with a larger diameter provides more mechanical advantage, but it can cause you to hike your shoulders during the stroke, which can be more stressful.”

That tricky equation leads Ludovici to acknowledge another truth common to complex rehab technology scenarios and clients: “Focusing on the three factors listed above, setting up a chair is always a balancing act and specific to each client. Improving setup for one factor might be a detriment to another. There is no generic right answer that applies to the masses.”

Proper Seating & the Impact on Shoulder Health

The self-propelling activities of manual wheelchair users make it easy to focus on the mobility aspect of shoulder health. But seating & positioning also plays an important role.

For instance, “Seat/back angles impact trunk stability, which in turn impact shoulder function through the concept of trunk stabilization,” Ludovici says. “Trunk stability is critical to efficient propulsion.” Seating components — wheelchair backrests, seat cushions, etc. — can also impact shoulders.

“Seating & positioning components have a direct effect on strain put on the upper extremities,” Ludovici says. “Selecting the correct seating & positioning products will result in stability. The more the system provides stability, the less repositioning you will find yourself doing, which results in a decreased amount of stress.” Ludovici also points out the importance of overall efficiency and energy conservation throughout the day — and how they can affect a wheelchair user’s health.

“Ultimately, you have a system, and you need to propel it,” he says. “Every bit of movement necessary to achieve [seating] stability is energy wasted that could have gone into propelling yourself. The correct and appropriate seating & positioning components will work with you and not against you.”

As usual, dialing in the most efficient seating system for an ultralight user means acknowledging the compromise inherent to the situation.

“In any successful balance, there is always a give-and-take system,” Ludovici says. “It is highly personalized on what you’re willing to give and what you’re willing to take. Do you want an easier transfer or easier propulsion?”

Help & Advice from Professionals

Given what’s at stake for ultralight users — and how imperfect environments can be for rolling mobility — what can assistive technology professionals do to help their clients maintain healthy and strong shoulders for life?

An ATP or clinician can’t do much regarding the extra propelling a client has to do to find a curb-cut or ramp, but Tom Whelan, Ki Mobility’s VP of product development, thinks they can definitely have an impact on other parts of the equation.

“Experienced seating and mobility professionals have a great deal of understanding with regards to transfers and repositioning,” he says. “What is less understood is the mechanics of propelling the wheelchairs. This is where we can improve on the science and education.”

From his personal perspective as a long-time self-propeller, Ludovici says, “We understand that [in-patient] rehab is constrained on time, and the main focus is independence. However, when you think about a ‘lifetime of wheelchair strokes,’ it may be more beneficial to the client and preservation of their upper body to focus on the technique of the strokes — to reiterate the importance of weight lifting and body strengthening to help against shoulder degeneration.

“What I have learned from my own experience is that alternating seat position in relation to the wheels can not only strengthen the muscles, but it also helps preserve the upper extremities.”

From the MM Library: Ultralight Usage

More from the Mobility Management editorial archives (go to, and use the Search function):

Research: Understanding Wheelchair Propulsion
Dr. Stephen Sprigle’s research series (MM November 2014 and January 2015) examines the performance differences between lightweight and ultralightweight manual wheelchairs. Search words: Manual Chair Propulsion (for part I) and Ultralight Research (for part II).

Justify It: K0005 Manual Chairs
Examining clinical justification for ultralight chairs, as well as the documentation needed to secure reimbursement. Search words: Justify It (for a story on adult and a second story on pediatric ultralight chairs).

The Ergonomics of Ultralights
Optimizing setups for self-propelled wheelchairs. Search word: Ergonomics.

This article originally appeared in the June 2015 issue of Mobility Management.

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