Download Wh l h i inj eelchair user injury

Wh l h i user injury
Wheelchair
inj
Reporter: Hsiao-Hui Chiu
Adviser: Lin-Hwa Wang
Outline
• Introduction
• Wheelchair use injury
- wheelchair user
- wheelchair athletes
• Other effect factor: Wheelchair camber
• Discussion
Di
i
• Summaryy
Introduction
• The high prevalence of injury in
wheelchair users may be related to the
repetitive use of the upper limbs during
functional routines and wheelchairrelated activities.
• Soft tissue injuries occur most
commonly at shoulders, elbows, wrists,
and hands.
hands
Madorsky, 1984
Introduction
• Injuries: include muscle pulls, strains,
sprains,
i
bursitis,
b iti and
d tendonitis.
t d iti Many
M
of these injuries are recurrent.
Madorsky, 1984; Bayley, 1987
• Cause
Cause:
- tearing and overstretching of ligaments
during falls or physical contact
- chronic overuse of muscles and tendons
- over-exertion without proper warm-up
Madorsky 1984
Madorsky,
Wheelchair use injury
• Wheelchair user or athletes shoulder
pain is a serious and frequent
p
in patients
p
with hemiplegia
p g
complication
and chronic spinal injury.
Griffin, 1981; Burnham,1993; Nawoczenski, 2006
• Pain-sensitive soft tissue surrounding the
glenohumeral joint (GH)—
(GH) rotator cuff
cuff,
joint capsule, subacromial bursa, and
b
biceps
brachii
b h tendon—is
d
subject
b
to many
stresses.
Griffin, 1981
Wheelchair injurywheelchair user
Injury- wheelchair user
• 58% (76/130) reported
t d Upper
U
extremity
t
it
pain after spinal cord injury: (questionnaire)
-
71%
53%
43%
35%
shoulder pain
wrist pain
hand
h d pain
i
elbow pain
p
Dalyan,1999
Injury- wheelchair user
• After injury 2 – 4years,
4years wheelchair user
shoulder pain prevalence was 70%
(19/27) : (use WUSPI)
Salisbury,2006
• 33% wheelchair-bound paraplegics had
chronic, persistent shoulder pain that was
clinically diagnosed as rotator cuff
impingement syndrome.
Bayley, 1987
Injury- wheelchair user
Shoulder impingement syndrome (SIS):
clinical diagnosis based on the patient’s
patient s history and physical
• Shoulder rotator cuff impingement
findings
y
is a common and disabling
g
syndrome
Repetitive trauma to the rotator cuff
ff
problem for the wheelchair
athlete. ※
↓
Burnham,, 1993
edema and hemorrhage in the rotator cuff
↓
hypertrophy of the synovium and the subacromial bursa
↓
Chronic narrowing of the acromiohumeral distance (compression
of the subacromial bursa or the supraspinatus tendon)
↓
Pain
Brossmann, 1996
Injury- wheelchair user
• Wrist injury
injury- carpal tunnel syndrome
- ↑ length of time since the injury of the
paraplegia ↑ the prevalence of the
paraplegia,
symptoms
- In the paraplegic patients, whether or not
they had carpal tunnel syndrome
syndrome, when
the wrist extension, the pressures were
significantly higher than those in nonnon
paraplegic patients.
Gellman, 1988
Injury- wheelchair user
- The pressure in the carpal canal during
this forced extension of the wrist:
→ when
h propelling
lli a wheelchair,
h l h i
combined with the repetitive trauma to
the volar aspect of the extended wrist
→lead to the high frequency with which
carpal tunnel syndrome is found in
paraplegic patients
patients.
Gellman, 1988
Tetraplegia VS. Paraplegia
• Shoulder pain: tetraplegia VS. paraplegia
(WUSPI)
- Paraplegia performed significantly more
wheelchair transfers per day and
performed significantly more hours per
weekk d
driving
i i than
th tetraplegia.
t t l i
Curtis, 1999
Tetraplegia VS. Paraplegia
- More than 2/3 of the sample (total 195
195,
tetraplegia for 92 and paraplegia for 103)
reported
t d shoulder
h ld pain
i since
i
beginning
b i i
wheelchair use.
- Wheelchair user had shoulder pain (2/3):
- Tetraplegia:
p g 59%
- Paraplegia: 42%
Curtis 1999
Curtis,
Tetraplegia VS. Paraplegia
- Compared 3 age groups (~30 yr, 31-40
yr, 40~
40 yr),
) individuals
i di id l with
ith tetraplegia
t t l i
showed higher WUSPI scores in each
age group.
Curtis, 1999
With VS. without upper-limb
pp
impairment
p
• Wheelchair user with VS.
VS without upperupper
limb impairment
- Upper-limb
Upper limb impairment: paralysis,
paralysis paresis,
paresis
sensory impairment, motor control deficits,
pain restricted joint motion
pain,
motion.
- Kinematics & Kinetics
Finley, 2004
With VS. without upper-limb
pp
impairment
p
- With upper-limb impairment during the
contact
t t phase
h
g e st
stroke
o e frequency
eque cy
→higher
→reduced hand-rim contact time
→smaller peak joint angles and joint
excursion of the wrist,, elbow,, and
shoulder
Finley,
y, 2004
With VS. without upper-limb
pp
impairment
p
- With upper-limb impairment during the
release phase
→greater wrist extension
→smaller shoulder abduction angles
Finley, 2004
With VS. without upper-limb
pp
impairment
p
- With upper-limb impairment during the
propelled
→reduced power forces
→reduced hand-rim
hand rim propulsive and resultant
force, moment, and joint compressive
fo ces
forces.
Finley 2004
Finley,
Wheelchair
Wh
l h i injuryi j
wheelchair athletes
Injury- wheelchair athletes
• To analysis wheelchair basketball
athletes in Taiwan (2001), the athletes
(total 165) the upper extremities injury
proportion was 75.7%.
- Finger/wrist/hand 30%
- Upper arm/shoulder 30%
- Forearm/elbow 15.7% ※
Chang, 2004
Injury- wheelchair athletes
• The most commonly reported type of
injury in wheelchair basketball athletes
(2001):
- Muscle injuries: 51.4%
- Ligament sprains: 14.3%
- Blisters: 11
11.4%
4%
- Concussion: 8.6%
- Lacerations/abrasions: 12.9% ※
Chang 2004
Chang,
The muscle imbalance
• Potential causes of this shoulder pain
could be myriad.
• The muscle imbalance mayy be a factor
of Shoulder pain causes.
Burnham, 1993
The muscle imbalance
• The paraplegics’ shoulders were stronger
than the able
able-bodied
bodied in all directions.
directions
• As compared able-bodied, the strength
ratio of abduction:adduction was higher for
paraplegic athletes.
Burnham 1993
Burnham,
The muscle imbalance
• Paraplegics’
Paraplegics shoulders with rotator cuff
impingement syndrome had higher
abduction:adduction and
abduction:internal rotation strength
ratios
ti th
than th
the shoulders
h ld
off paraplegics
l i
without impingement syndrome.
Burnham, 1993
The muscle imbalance
• Relative weakness of shoulder
adduction, as compared to abduction,
Abduction
(deltoid
muscle function)
was
foundstrength
in the all
paraplegic
athlete
↓
group.
No balancing force of the ‘shoulder
shoulder depressors’
depressors
• This pattern
even
(obliquewas
rotator
cuff more
& Adductor)
exaggerated
e
agge a ed in the
e ↓pa
paraplegic
ap eg c a
athletes
e es
Deltoid
pullscuff
the humeral
head cephalad
with
rotator
impingement
((constricts※the acromiohumeral space)
p
)
syndrome
syndrome.
↓
Burnham, 1993
cause shoulder rotator cuff impingement.
p g
The muscle imbalance
• In isokinetic test ((180°s-1 and 300 °s-1)
- able-bodied tennis player VS. wheelchair
tennis athletes
→the internal/external muscle ratio for both
sides showed the significantly higher
sides,
values in the wheelchair tennis athletes.
Bernard, 2004
The muscle imbalance
→meaning
meaning wheelchair athletes
athletes’ shoulder
muscle strength ratio were more
imbalance than able-bodied
able bodied tennis
player, so their injury risk were higher.
Bernard, 2004
Other effect factor:
wheelchair camber
wheelchair camber
• Among the adjustments of the wheelchair,
wheelchair
the wheel camber is an important
parameter to take into account when
trying to attain the optimal ergonomic
adjustment of a sport wheelchair to its
user.
Faupin, 2008
• Because the design the camber of the
wheelchair will direct effect wheelchair
athletes’ upper kinematic and kinetic.
athletes
kinetic
Wheelchair Camber
• The wheel camber corresponds to the
angle of the rear wheel in relation to
the vertical.
vertical ※
Higgs, 1983
Increase camber
↓
the contact area of tire and ground will increase
↓
friction force increase
(stronger rolling resistance)
↓
leads to prolonged hand-wheel
hand wheel contact,
contact which makes the
push time longer
Faupin, 2004
↓
mean velocity per arm cycle (Vm) decrease
decrease.
wheelchair camber
• With increase wheel camber (9°,
(9 , 12
12°,,
15°), the mean velocity per arm cycle
(Vm) decrease.
decrease ※
• When the rolling resistance increase,
th user need
the
d spend
d more force
f
to
t
attain the same speed, the easier
muscles fatigue, so they had the higher
injury
j y risk.
wheelchair camber
• The camber camber(0°,
camber(0 , 9
9°,15°)
,15 ) increase
to 15°, significant increase the loading
of each joint
joint.
• The shoulder moment was larger than
other joint moment.
• The wrist moment increased the most
intensely.
Tsai 2007
Tsai,
wheelchair camber
• When increase wheelchair camber(0° to
), the joint
j
moment become higher,
g ,
15°),
so the joint loading increase lead to
user get hurt more easily
easily.
Tsai, 2007
Discussion
• Wh
Wheelchair
l h i propulsion
l i is
i low
l
efficiency
ffi i
work.
Tsai, 2007
• The most common injury in wheelchair
user or athletes is upper extremities injury,
for whom it appears necessary to improve
overall muscle endurance and strength
g
and to increase the duration of resting
intervals in order to attempt to reduce
j y frequency.
q
y
injury
Discussion
• Muscles strengthening and stretching,
and proper propulsion activity could be
an effective prophylactic and treatment
of injury. ※
N
Nawoczenski,
ki 2006
• The most popular treatment were
physiotherapy, massage and heat.
Salisbury, 2006
Summary
• To wheelchair user, the upper extremity
serious injury might effect their quality of
life, above all the shoulder pain is the
primary injury, and second is wrist pain.
• Otherwise, the wheelchair camber is one
off iincrease upper extremity
t
it iinjury
j
risk:
i k
pp joint
j
the camber increase → the upper
moment increase → increase joint loading
→ muscle fatigue
g easilyy → the injury
j y risk
increase.
Summary
• When design wheelchair, how to get
the balance and best benefit between
the wheelchair perform functional and
user body condition are the most issue
t th
to
the d
designer
i
and
d trainer.
t i
Thanks for your attention!!