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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!!