R3 Research and Development

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Overview of Research and Development Activities


State of the Science on Spinal Cory Injury


Research Projects: Effect of Local Cooling | Effects of Weight Shifting | Handrim Technology


Development Projects: Inflammation Modeling | Low Shear, Cool Cushion | Propulsion Training Tools


 

R3 Effects of handrim technology on upper extremity musculoskeletal injury

Task Leader(s): Michael Boninger, MD

Co-Investigator: Dan Ding, Ph.D.

Other participants: Annmarie Kelleher, MS (clinical coordinator) and Brad Impink MS (mechanical engineer, Bioengineering Masters student) Michelle Oyster (MSE, clinical coordinator), Erica Authier (MSE, SHRS PhD student); Jennifer Collinger (BSE, Bioengineering PhD student).

 


Specific Aims

Aim 1: Determine differences in EMG and metabolic responses for wheelchair propulsion with: standard handrims, the Natural-Fit Handrim (NFH) and the FlexRim (FR).

Hypothesis 1a: EMG activity in the forearm and upper arm muscles for propulsion with both the NFH and the FR will be significantly lower than with the standard handrims.

Hypothesis 1b: Metabolic activity for propulsion with both the NFH and the FR will be significantly lower than with the standard handrims.

Note: These tests will also enable determination for any differences between the NFH and FR.

Aim 2: Determine differences in the acute response of the median nerve for wheelchair propulsion with standard handrims, NFH and FR.

Hypothesis 2a: The median nerve cross-sectional area (CSA) will be significantly less and the flattening ratio will be significantly greater for propulsion with the standard handrim than for propulsion with NFR and FR.

Hypothesis 2b: Any changes resulting from propulsion with the ergonomic handrims will return to baseline values faster than changes resulting from propulsion with the standard handrim.

Aim 3: Determine differences in the acute responses of the rotator cuff tendons for propulsion with: standard handrim, NFH and FR.

Hypothesis 3a: Echogenicity will be significantly less and the diameter will be significantly greater for the tendons of the supraspinatus, infraspinatus and long head of the biceps after propulsion with the standard handrim than propulsion with NFR and FR.

Hypothesis 3b: Any changes resulting from propulsion with the NFH or FR will return to baseline values faster than changes due to propulsion with the standard handrim.


Background and Rationale

Ergonomics literature has defined tasks involving high forces, high repetition and large joint excursions as risk factors for musculoskeletal injuries. Manual wheelchair propulsion is such a task. The prevalence of wrist and shoulder pain has been observed to be as high as 73% among manual wheelchair users (MWUs). The development of an ergonomic handrim that eases the stress on the arms and decreases the likelihood of pain and secondary upper extremity injuries would be very beneficial for MWUs. Wrist and shoulder pain decreased for a group of MSUs following their use of the Natural-Fit Handrim (NFH) for six months in place of standard wheelchair handrims. The FlexRim (FR), another ergonomic handrim has been shown to require less forearm muscle activity compared to a standard handrim.

Cumulative trauma disorders (CTDs) typically result from repetitive micro trauma that damages local tissue. A determination of differences in metabolic responses of the upper extremities when using the respective handrims may provide relevant information on the acute responses of nerves and tendons to micro trauma and provide insight on CTDs and the benefits of ergonomic handrims. Ultrasound has been used to measure acute shape and size changes in nerves and tendons after a provocative activity.

We shall determine differences for muscle activity, metabolic activity, and nerve and tendon responses for wheelchair propulsion with standard handrims, the Natural-Fit Handrim and the FlexRim.

The Natural-Fit Handrim (NFH)
The Natural-Fit (www.thenaturalfit.com) consists of a smooth oval surface for the palm of the hand and a higher friction contoured slot for the thumb (Figure 1). These components combine to provide an ergonomic grip and separate surfaces for propulsion and braking. The Natural-Fit is designed to eliminate the pinch grip associated with a standard handrim and to ease stress on the hands and wrists during propulsion. The Natural-Fit has been commercially available since 2003.

Figure 1

Figure 1 - The natural-fit handrim

The FlexRim
The FlexRim (www.flexrim.com) consists of a high friction rubber surface that connects a standard aluminum handrim to the wheel (Figure 2). The rubber connecting surface is flexible and conforms to the thumb and thenar eminence when gripped. The FlexRim's compliant rubber surface is designed to ease stress during propulsion by creating "give" in the connection point between the handrim and the wheel to absorb propulsion impact forces. The FlexRim is produced by Spinergy and is slated for market entry in the near future.

Figure 2

Figure 2 - The FlexRim

 


Research Design and Methods

Study Population

25 individuals meeting the following criteria will be recruited for this study:

Inclusion Criteria:

  • Spinal cord injury below T1 that occurred after the age of 18 and at least one year prior to enrolling in the study
  • Use a manual wheelchair as their primary means of mobility (> 80% of their ambulation)
  • 18-65 years of age

Exclusion Criteria:

  • History of fractures or dislocations in the shoulder, elbow and wrist

We include individuals with paraplegia only for sample homogeneity. We believe our results will apply to a majority of manual wheelchair users. Previous experience in testing subjects with paraplegia at varying segmental levels with corresponding states of trunk paralysis indicates that this source of variation does not alter propulsion mechanics for the events we propose in this investigation. Subjects with a history of traumatic injury to the upper limb will be excluded. Finally, it has been our experience that subjects injured before age 18 have altered upper and lower limb growth that affects biomechanics.

Data Collection

We will conduct the following tests and measurements:

  1. History and physical exam
  2. Baseline ultrasound examination
  3. Metabolic and EMG wheelchair propulsion analysis with NFH, FR or standard handrim (order will be randomized)
  4. Over-ground propulsion with NFH, FR or standard handrim
  5. Follow-up ultrasound examination
  6. Repeat steps 2-5 (handrim will be changed for steps 3 and 4)
  7. Repeat steps 2-5 (handrim will be changed for steps 3 and 4)

 


Project Update

2012

The task was completed in 2010. Dissemination of the results has continued during this reporting period. Please see list of publications.

2011

The task has been completed. The final sample size was 17, which was short of our original goal. The recruitment was stopped because no differences were seen in the data. We conducted an interim power analysis that revealed that over 144 subjects would be needed to detect a difference in pushrims using the proposed metrics. We therefore accepted the null hypothesis that we could not detect differences in pushrims. Despite our negative results, we advanced the science of detecting acute changes in upper limb soft tissue structures during wheelchair propulsion and other activities. We published repeatability data on ultrasound measures of the biceps tendon and the median nerve. Objective, valid measures of tendon health are needed to investigate interventions aimed at reducing pathology and secondary injuries in wheelchair users. We also published additional data on changes seen in these structures related to wheelchair propulsion. These findings further our ability to make specific recommendations to individuals with spinal cord injury that will protect them from secondary disability. We have published a number of studies and presented at numerous medical meetings. Our ultrasound measurement techniques are now being used by investigators outside of Pittsburgh, including at The Miami Project.

2010

Testing and data collection was completed for 17 participants. The study is currently in the data analysis phase. Median nerve images for all subjects have been analyzed. EMG and metabolic data analysis is underway.

Three publications were submitted, two of which have been highlighted as Most Important in the outputs section. The publications describe an objective measures capable of quantifying rotator cuff tendon health that were found to be related to clinical measures of shoulder pathology. This demonstrates external validity of the measure. Objective, valid measures of tendon health are needed to investigate interventions aimed at reducing pathology and secondary injuries in wheelchair users. We can now use these techniques to determine if using a ergonomically designed wheelchair push rim results in less changes at the rotator cuff tendon then a standard wheelchair. The measurement tool has been highlighted as a Type 2 output.

2009

The IRB protocol has been approved and subject recruitment is underway. Through protocol development work, investigators have found evidence to support that images taken of the quantitative ultrasound measures of the long head of the biceps tendon have good intra-rater reliability and a limited standard error of measurement among non-wheelchair users. This finding supports the use of pre- and post-activity images to detect tendon changes after a strenuous period of physical activity. Publications are in preparation that show the reliability of data collected using the upper extremity ultrasound protocol and work is underway to show the same results for the new researcher that is to collect this study's ultrasound images. We have also shown that there are significant changes in structures with activity, when measured with ultrasound. The project staff has prepared for an additional data collection component; blood samples for the D1 modeling task will be collected just prior to wheelchair propulsion tests and immediately following completion of all propulsion activities for use in development of the preliminary, agent-based model of inflammation and healing of upper extremity injury. Investigators have worked to prepare the laboratory for the collection and preparation of blood samples including the purchase of vital equipment, the completion of a phlebotomy training course and internship, as well as blood borne pathogen training and shipping modules. The laboratory have received approval to collect human blood draws outside of clinical space.

2008

We have received IRB approval and have opened recruiting for the study.

 


Publications

Abstracts

Gagnon, D, Collinger JL, Impink B, Koontz AM, Boninger M. Reliability of Quantitative Ultrasound Measures of the Biceps Tendon: A Preliminary Study Among Non-Wheelchair Users. Annual scientific congress of Rehabilitation Engineering and Assistive Technology Society of North America, Washington, District of Columbia, USA 2008.

Gagnon, D, Boninger M, Collinger JL, Impink B, Koontz AM. Do Stroke Characteristics Change During a High-Intensity 12-minutes Corridor Wheelchair Propulsion Test in Experienced Manual Wheelchair Users?
Annual scientific congress of Rehabilitation Engineering and Assistive Technology Society of North America, Washington, District of Columbia, USA 2008.

Turkovich, M, Koontz, A, Cowan, R, Rice, I, Boninger, M. The Effect of Shoulder Position on Pushrim Forces during Overground Manual Wheelchair Propulsion. Annual scientific congress of Rehabilitation Engineering and Assistive Technology Society of North America, Washington, District of Columbia, USA 2008.

Kankipati, P, Koontz, A, Turkovich, M. Shoulder Joint Loading for Three Types of Lateral Wheelchair Transfers. Annual scientific congress of Rehabilitation Engineering and Assistive Technology Society of North America, Washington, District of Columbia, USA 2008.

Wang, H, Koontz, A, Collinger, J, Boninger, M. Influence of Gripping Moments during Wheelchair Propulsion on Natural Surfaces. Annual scientific congress of Rehabilitation Engineering and Assistive Technology Society of North America, Washington, District of Columbia, USA 2008.

Worobey L, Koontz-, A.M.; Tamburo, E.; Boninger, M.L. (2011). Comparison Of Upper Extremity Electromyography During Manual Wheelchair Propulsion With Three Handrims. Proceedings of the RESNA 2011 conference. Toronto, ON, Canada.

Manuscripts

Gagnon D, Boninger M, Impink B, Collinger J, Koontz A. Preliminary Development of a High-Intensity Corridor Propulsion Test For Manual Wheelchair Users. Will be submitted to Archives of Physical Medicine and Rehabilitation in February 2008

Rice I, Gagnon D, Boninger M, [name of last author unknown]. Manual Wheelchair Propulsion Training Using a Biomechanical Feedback-Based Learning Software. Will be submitted to Journal of Neuroengineering and Rehabilitation in March 2008

Impink BG, Boninger ML, Walker H, Collinger J, Ultrasonographic Median Nerve Changes After a Wheelchair Sporting Event, Archives of Physical Medicine and Rehabilitation , pp. 1489-1494, Vol. 90, No. 9, September 2009.
Collinger JL, Gagnon D, Jacobson J, Impink BG, Boninger ML, Reliability of Quantitative Ultrasound Measures of the Biceps and Supraspinatus Tendons, Academic Radiology, 2009 Nov;16(11):1424-32. Epub 2009 Jul 10.
Impink BG, Gagnon D, Collinger JL, Boninger ML, Ultrasonographic Median Nerve Repeatability, Muscle and Nerve Volume 41, Issue 6, Date: June 2010, Pages: 767-773.

Collinger JL, Fullerton B, Impink BG, Koontz AM, Boninger ML, Validation of Greyscale Based Quantitative Ultrasound: Relationship to Established Clinical Measures of Shoulder Pathology, American Journal of Physical Medicine and Rehabilitation,2010 May;89(5):390-400.

Impink, BG.; Collinger, JL.; Boninger, ML. (2011). The Effect of Symptoms of Carpal Tunnel Syndrome on Ultrasonographic Median Nerve Measures before and after Wheelchair Propulsion. PM&R, 3(9), 803-10.

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This work is funded by the National Institute on Disability and Rehabilitation Research (NIDRR),
Rehabilitation Engineering Research Center (RERC) on Spinal Cord Injury, Grant #H133E070024
The ideas and opinions expressed herein are those of the authors and not necessarily reflective of the NIDRR.

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Last Updated: 07.10.2012 | 16:10

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