|R3||Research and Development|
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).
Aim 1: Determine differences in EMG and metabolic responses for wheelchair propulsion with: standard handrims, the Natural-Fit Handrim (NFH) and the FlexRim (FR).
Aim 2: Determine differences in the acute response of the median nerve for wheelchair propulsion with standard handrims, NFH and FR.
Aim 3: Determine differences in the acute responses of the rotator cuff tendons for propulsion with: standard handrim, NFH and FR.
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)
Figure 1 - The natural-fit handrim
Figure 2 - The FlexRim
Research Design and Methods
25 individuals meeting the following criteria will be recruited for this study:
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.
We will conduct the following tests and measurements:
The task was completed in 2010. Dissemination of the results has continued during this reporting period. Please see list of publications.
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.
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.
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.
We have received IRB approval and have opened recruiting for the study.
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?
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.
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, 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.
This work is funded by the National Institute on Disability and Rehabilitation Research (NIDRR),
Last Updated: 07.10.2012 | 16:10