1151

A New Method to Quantify Demand on the Upper Extremity

During Manual Wheelchair Propulsion
Michelle B. Sabick, PhD, Brian R. Kotajarvi, PT, Kai-Nan An, PhD
ABSTRACT. Sabick MB, Kotajarvi BR, An K-N. A new
method to quantify demand on the upper extremity during
manual wheelchair propulsion. Arch Phys Med Rehabil 2004;
85:1151-9.
Objective: To use an ergonomics-based rating that characterizes both demand on, and capacity of, upper-extremity muscle groups during wheelchair propulsion to help identify the
muscle groups most at risk for pain or overuse injury in a
relatively demanding wheelchair propulsion task.
Design: Case series.
Setting: Biomechanics research laboratory.
Participants: Sixteen manual wheelchair users with complete (American Spinal Injury Association grade A) T6-L2
paraplegia.
Interventions: Not applicable.
Main Outcome Measures: Internal peak joint moments
required by each of the major upper-extremity muscle groups
for propelling a wheelchair up a ramp; isometric strength of
each of the muscle groups in positions simulating wheelchair
propulsion; and wheelchair propulsion strength rating (WPSR)
for each muscle group, calculated by normalizing the joint
demands to their capacity.
Results: The largest joint moment was for shoulder flexion, at
39.713.9Nm. Shoulder flexion also accounted for the peak
WPSR value of 66.5%20.3%. Supination and pronation movements had low peak moment requirements (3.4Nm, 5.0Nm, respectively) but high WPSR values (41%, 53%, respectively).
Conclusions: Even a relatively benign ramp (2.9) places a
large demand on the musculature of the upper extremity, as
assessed by using the WPSR to indicate muscular demand.
Key Words: Biomechanics; Elbow; Rehabilitation; Shoulder; Wheelchairs; Wrist.
2004 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and
Rehabilitation
Y PROVIDING MOBILITY, wheelchairs are uniquely
important to the functional independence of people with
B
disabilities and are an integral part of rehabilitation medicine.
However, long-term wheelchair users suffer from a variety of
overuse syndromes of the upper extremity.1-7 At any time,
approximately 68% of manual wheelchair users complain of

From the Orthopedic Biomechanics Laboratory (Sabick, An) and Motion Analysis
Laboratory (Kotajarvi), Mayo Clinic, Rochester, MN USA. Sabick is currently
affiliated with the Center for Orthopaedic and Biomechanics Research, Department of
Mechanical Engineering, Boise State University, Boise, ID.
Presented in part at the American Society of Biomechanics 23rd annual meeting,
October 1999, Pittsburgh, PA.
Supported by the National Institutes of Health (grant nos. HD33806, HD07447).
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the authors(s) or upon any
organization with which the author(s) is/are associated.
Reprint requests to Michelle B. Sabick, PhD, Center for Orthopaedic and Biomechanics Research, Dept of Mechanical Engineering, Boise State University, 1910
University Dr, Boise, ID 83725-2075, e-mail: MSabick@boisestate.edu.
0003-9993/04/8507-8206$30.00/0
doi:10.1016/j.apmr.2003.10.024

some type of upper-extremity pain.2 Generally, the shoulder is

the source of most complaints.3,8-10 The incidence of shoulder
injury or pain is between 30% and 52% in the manual wheelchair user population.1,2,8,9 In a group of female basketball
players with paraplegia, 72% complained of having some
shoulder pain since starting to use a wheelchair, with the most
painful activities including household chores, propelling up
ramps or slopes, and lifting overhead.8
Complaints consistent with carpal tunnel syndrome (CTS)
and other wrist maladies are also common.2,10-13 Gellman et al2
found that 49% of a group of patients with paraplegia had signs
and symptoms of CTS. Gellman speculated that the high incidence of median nerve dysfunction was caused by several
activities of daily living involving pressure applied to an extended wrist, including manual wheelchair propulsion. Boninger et al14 found that pushrim biomechanics and body weight
were both related to median nerve function; they therefore
believed that manual wheelchair propulsion may have a role in
the development of median nerve disorders. However, in an
earlier study,7 they found that elite wheelchair racers did not
have an increased incidence of median nerve disorders compared with the overall population of manual wheelchair users,
even though they propelled their wheelchairs an average of
more than 50 miles a week.
Although manual wheelchair use has been implicated as a
cause of upper-extremity overuse injuries, relatively few rigorous scientific data are available to relate wheelchair propulsion biomechanics to specific upper-extremity overuse injuries.
Research has suggested that relatively high joint moments exist
at the shoulder during wheelchair propulsion.15-19 Over time,
these large moments are thought to lead to upper-extremity
overuse injury. Wrist joint moments are generally smaller than
moments at the shoulder or elbow. For example, Robertson et
al15 found mean peak moments of 19.6, 12.3, and 5.78Nm at
the shoulder, elbow, and wrist, respectively. Magnitudes of the
joint forces and moments change significantly, based on the
speed of propulsion,18,19 ramp angle,18,19 handrim diameter,20
and other factors.
The relative magnitudes of joint moments at the shoulder
and elbow are roughly double the peak wrist joint moments
required during propulsion. However, the wrist is still a common source of complaints in wheelchair users. This suggests
that the magnitude of joint moments alone is not a good
indicator for risk of overuse injury. Ergonomic research suggests that neither isometric strength nor job demand is a sensitive predictor of job-related injury on its own.21,22 However,
when job demands relative to maximum isometric strength are
considered, a sensitive predictor results.21 Chaffin et al23 defined a job strength rating (JSR), for predicting job-related
injuries, as the ratio of maximum strength requirement of the
job to the average isometric strength of the workers doing that
job.23 The study showed that injury is more likely to occur
when a person is performing a task at or near maximum
exertion, as reflected by a higher JSR value.
The purpose of our study was to apply these principles of
ergonomic injury research to manual wheelchair propulsion.
We have proposed a wheelchair propulsion strength rating,
Arch Phys Med Rehabil Vol 85, July 2004

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UPPER-EXTREMITY DEMAND IN WHEELCHAIR PROPULSION, Sabick

Table 1: Anthropometric Characteristics of the 16 Subjects, All of Whom Were Low-Level Paraplegic Manual Wheelchair Users
Subject

Age (y)

Height (m)

Weight (kg)

Injury Level

Cause of Injury*

Years Since Injury

B
C
D
E
F
K
L
M
N
O
P
Q
R
S
Y
Z

39
36
37
24
46
35
37
50
46
36
48
40
39
33
38
40

1.80
1.83
1.73
1.74
1.83
1.73
1.79
1.80
1.78
1.83
1.78
1.72
1.58
1.63
1.88
1.88

61
85
66
69
123
62
80
91
87
106
79
64
71
58
116
72

T12
T12
L1
T12
T12
T12
T10
L2
L1
T11
T6
T10
T11
T11
T11
T12

SCI
SCI
SCI
SCI
SCI
SCI
SCI
MS
AVM
SCI
SCI
SCI
SCI
SCI
SCI
SCI

5
5
11
5
19
8
20
15
8
19
26
18
8
15
4
19

*Cause refers to the cause of paraplegia, either SCI, MS, or AVM.

similar to the JSR proposed by Chaffin,23 for assessing the

likelihood of overuse injury in manual wheelchair users. This
new rating, which will be referred to as the wheelchair propulsion strength rating (WPSR), may be useful for predicting
muscle and tendon injuries caused by long-term wheelchair
use. Our hypothesis is that the WPSR will provide additional
insight into the demands being placed on the upper-extremity
muscle groups because it takes into account both demand and
capacity for each joint motion. WPSR data for a group of
wheelchair users performing a moderately difficult wheelchair
propulsion task will be presented and discussed in light of
previous biomechanic studies and clinical injury patterns.
METHODS
Participants
The forces and moments exerted on the handrim during
wheelchair propulsion were recorded in 16 adult wheelchair
users (14 men, 2 women) with low-level paraplegia (T6-L2;
table 1) caused by spinal cord injury (SCI), multiple sclerosis
(MS), or arteriovenous malformation (AVM). Each subject had
been using a wheelchair as his/her primary means of mobility
for at least 4 years. All subjects used a Quickie IIa manual
wheelchair with removable rear wheels. Before testing, a clinical history and physical examination were performed to screen
potential participants for upper-extremity pathology. Subjects
were excluded if they had any of the following clinical signs:
painful arc of shoulder motion; pain with resisted shoulder
flexion, abduction, or external rotation and elbow flexion and
extension; or the presence of acute or chronic history of upperextremity pain. Based on these criteria, 16 of a pool of 22
potential subjects were accepted into the study. On arrival at
the laboratory, subjects provided informed consent, and their
weight was measured by using a wheelchair scale. The commercial wheels on the subjects wheelchair were removed and
replaced with custom wheels containing instrumented handrims (fig 1). Proper fit of the wheelchair to the user was
evaluated by a licensed physical therapist with 10 years experience treating individuals with paraplegia. In no case did
adjustments need to be made to improve fit of the wheelchair
to the user. Use of subjects own wheelchairs ensured proper fit
of the wheelchair to the subject over the range of subject body
sizes.
Arch Phys Med Rehabil Vol 85, July 2004

Data Collection
Subjects propelled their wheelchairs up a moderately inclined ramp (fig 2), with a 20:1 run to rise ratio, corresponding
to an inclination angle of 2.9. This ramp slope was chosen
based on guidelines for construction of ramps as set forth in the
Americans with Disabilities Act and the building code of the
State of Minnesota. We chose to present data collected on a
ramp because of the high incidence of upper-extremity pain
reported in ascending ramps.13 In addition, ramp propulsion is
a physically more demanding task than propulsion on level
ground,24 and ramps are a common hurdle encountered in
everyday life.
Each subject performed 5 trials of manual wheelchair propulsion up the ramp at a self-selected speed. The custominstrumented wheels mounted on the subjects wheelchair allowed us to record 3-dimensional handrim forces and moments

Fig 1. View of the instrumented handrim that was applied to the

subjects wheelchair. The handrim assembly was coupled to the
wheel through a 6-component load cell to record the forces and
moments applied to the handrim. A portable data logger was
mounted to the wheel to record data from the load cell and to
transfer it to a personal computer after each trial.

UPPER-EXTREMITY DEMAND IN WHEELCHAIR PROPULSION, Sabick

Fig 2. A subject propelling his wheelchair up the ramp. Reflective

markers are mounted on the subjects trunk and left upper extremity.

during wheelchair propulsion at 100Hz. The handrims were

instrumented with a commercial 6-component load cell.b The
accuracy of the instrumented handrims for measuring applied
force and moment has been reported.25 The handrim was
mounted to 1 side of the load cell, and the other side of the load
cell was mounted directly to the wheel (fig 1). Therefore, the 3
orthogonal force and moment components applied to the
handrim during propulsion were measured by the load cell
throughout the stroke cycle. A miniature data logger was
mounted to the wheel to store the load cell voltage data for the
duration of each trial. Load cell and motion data were synchronized with a common trigger. After each trial, the load cell data
were transferred to a personal computer. The load cell voltage
data were converted to force and moment values by using a
calibration matrix that corrected for any crosstalk between the
load cell channels.
The kinematics of the trunk and upper extremity were simultaneously recorded at 60Hz by using a commercial motion
analysis system.c Reflective markers were placed on 13 anatomic landmarks on the subjects trunk, arm, and hand (fig 3).
Five additional reflective markers were mounted on the wheelchair wheel so that the instantaneous location and orientation of
the wheel could be monitored.
Before each data collection session, the locations of the 6
cameras were adjusted so that each reflective marker on the
subject and the wheelchair could be seen by at least 2 cameras
throughout at least 1 full propulsion cycle. A view volume
approximately 212m covering the middle 2m of the runway was calibrated. The first full stroke cycle during which the
subject was completely within the calibrated volume was chosen for analysis. Both kinetic and kinematic data were collected
for the left upper extremity.
Data Processing
Three-dimensional marker coordinate data were smoothed
by using a generalized cross-validation spline smoothing

1153

(GCVSPL) routine with a cutoff frequency of 6Hz.26 Load cell

data were filtered by using the GCVSPL routine at a cutoff
frequency of 18Hz, as determined by residual analysis.27 All
additional calculations were performed by using custom routines written in Matlab,d which have been validated.25 Each
analyzable stroke was normalized to a percentage of the propulsion cycle (push and recovery) for subsequent data analysis.
The beginning of the stroke cycle was defined as the instant at
which any of the 3 handrim force components became positive
(after having been zero or negative during the recovery phase).
Four coordinate systems representing the orientations of the
trunk, upper arm, forearm, and hand were created by using the
13 reflective markers attached to the subject. Joint kinematics
were calculated by using the Euler angles to describe the
orientation of the distal segment reference frame relative to the
proximal segment reference frame at each joint.
The internal joint resultant forces and moments at the wrist,
elbow, and shoulder were determined by using an inverse
dynamic procedure. The relative mass and location of the
center of gravity of each segment as a function of subject body
height and weight were determined by using the segment
inertial data of Dempster.28 The moments of inertia for each
segment were determined by using the segment inertial data of
McConville et al.29 Joint resultant force and moment for each
upper-extremity joint were computed in an inertial reference
frame and projected onto the local segment coordinate systems
to provide anatomic reference. Joint forces are presented in the
coordinate system of the proximal segment. Joint moments in
the sagittal and frontal planes are also presented in the coordinate system of the proximal segment, whereas transverse
plane moments are presented in the distal segment coordinate
system, because the long axis of the distal segment is the axis
about which rotation occurs.
The peak joint moment occurring during each stroke cycle
was identified for each of the following 14 possible upper-

Fig 3. Locations of the 13 reflective markers applied to the upper

extremity and the orientations of the trunk, upper arm, forearm,
and hand coordinate systems. Reprinted with permission.49

Arch Phys Med Rehabil Vol 85, July 2004

1154

UPPER-EXTREMITY DEMAND IN WHEELCHAIR PROPULSION, Sabick

and forearm were secured in a right angle orthoplast shell by

using Velcro straps to minimize relative motion. Testing positions were chosen to simulate positions encountered in manual
wheelchair propulsion. For the flexion, extension, and rotation
tests, the shoulder was tested in the following position: neutral
flexion and rotation, 15 of abduction, 90 of elbow flexion,
and neutral forearm rotation. For abduction and adduction tests,
the arm was in the same position, except that the shoulder was
abducted 40. Repetitions were alternated between agonist and
antagonist muscle groups.
Elbow and wrist joint isometric strength were measured by
using custom torque cell dynamometers (fig 5).31,32 Subjects
performed each of the tests while seated in their own wheelchairs. A gait safety belt was used to stabilize the subjects
trunk within the wheelchair. The wheelchair was manually
stabilized by an assistant during the tests to ensure that the
subjects were able to put forth a maximal effort in each of the
strength tests without fear of tipping the chair. The wrist and
forearm were tested in a neutral position, with the elbow flexed
90. The shoulder was in a neutral position for all tests, except
for elbow flexion and extension; in these 2 cases, the shoulder

Fig 4. Views of a subject performing isometric strength testing of

shoulder (A) abduction and adduction and (B) internal and external
rotation by using the Cybex II isokinetic dynamometer. The arm and
trunk are secured by using Velcro bands.

extremity motions: shoulder flexion, extension, abduction, adduction, internal rotation, and external rotation; elbow flexion
and extension; pronation and supination; and wrist flexion,
extension, radial deviation, and ulnar deviation.
Strength Testing
Maximum voluntary isometric contractions for 14 upperextremity motions were collected after the wheelchair propulsion trials. Shoulder, elbow, and wrist joint isometric strengths
were measured by using a Cybex II isokinetic dynamometere
and custom torque cell dynamometers in standardized positions
simulating wheelchair propulsion. The strength measurement
techniques have been developed in our laboratory and are
documented in the literature.30-32
Shoulder flexion, extension, abduction, adduction, internal
rotation, and external rotation strengths were measured by
using the Cybex II isokinetic dynamometer (fig 4).30 The
subject was seated in the Cybex chair, and the trunk and pelvis
were stabilized by using straps. The subjects left upper arm
Arch Phys Med Rehabil Vol 85, July 2004

Fig 5. Two views of a subject performing (A) elbow flexion and

extension and (B) wrist flexion and extension joint strength tests by
using the custom torque cell dynamometers developed and validated in our laboratory.

1155

UPPER-EXTREMITY DEMAND IN WHEELCHAIR PROPULSION, Sabick

Table 2: Maximum Isometric Strength Values for the 16 Subjects
for Each of the Major Upper-Extremity Muscle Groups
Upper-Extremity Motion

Peak Torque (Nm)

Mean SD

Range

Shoulder abduction
Shoulder adduction
Shoulder extension
Shoulder flexion
Shoulder external rotation
Shoulder internal rotation
Elbow extension
Elbow flexion
Elbow supination
Elbow pronation
Wrist radial deviation
Wrist ulnar deviation
Wrist extension
Wrist flexion

46.610.6
84.218.2
67.815.9
61.513.4
37.18.2
57.414.4
44.814.3
66.513.9
7.82.1
9.92.5
12.32.6
15.13.3
7.31.9
12.53.2

2763
53114
43102
3579
2452
2679
23.577.1
32.187.9
3.911.1
4.713.1
7.917.4
9.521.7
3.110.4
8.219.3

NOTE. Values are mean standard deviation (SD).

was flexed approximately 50. Subjects were required to rest

the right upper extremity on the countertop at all times to
ensure that positioning and stabilization were consistent for all
subjects.
For all strength tests, data were collected for 4 seconds, and
3 repetitions were performed for each test. A 1-minute rest
period was allowed between trials. The mean of the peak
torque values for the 3 trials was used as a measure of strength
for that particular joint motion.
Calculation of WPSR and Maximum Joint Moment
During each trial, the maximum joint moment (Mmax) recorded during wheelchair propulsion for each of the 14 upperextremity joint motions was identified. These peak joint moments were used to compute the value of the WPSR by
normalizing them to the corresponding isometric strength, using the following equation:
WPSR

Maximum moment generated during propulsion (Nm)

Maximum isolated joint strength (Nm)
100

Therefore, the WPSR is an indication of the demand on specific

muscle groups during the propulsion cycle relative to the total
capacity of the individual to generate torque by using that same
muscle group.
RESULTS
Subject and Strength Data
The mean subject age was 396 years (range, 24 50y)
(table 1). The mean height and mass of the subject group were
1.770.08m (range, 1.58 1.88m) and 80.620kg (range, 58
123kg), respectively. The mean peak joint torques produced in
the strength tests are located in table 2. The largest torque
produced was for the shoulder adduction test, at 84.218.2Nm.
Extension and flexion torque values at the shoulder were similar, 61.513.4Nm and 67.815.9Nm, respectively. The
weakest shoulder muscle groups were the external rotators
(37.18.2Nm) and abductors (46.610.6Nm).
At the elbow, the flexors generated 66.513.9Nm of torque,
whereas the extensors were slightly weaker at 44.814.3Nm.

The supinators and pronators had similar torque values, with

pronation mean strength being slightly higher than supination
strength, although both values were relatively small
(9.92.5Nm, 7.82.1Nm, respectively).
At the wrist, the extensors were the overall weakest muscle
group (7.31.9Nm). The flexors, radial deviators, and ulnar
deviators all generated very similar mean torques, ranging from
12.3 to 15.1Nm.
Mmax Results
The mean peak moment demands required during wheelchair propulsion for each upper-extremity motion (Mmax)
ranged from a low of 2.11.3Nm for wrist extension to a high
of 39.713.9Nm for shoulder flexion (table 3). The maximum
demands at the wrist joint were all relatively small (mean
range, 2.13.5Nm), with ulnar deviation requiring the largest
moment, at 3.52.2Nm. The demands at the elbow were also
small, with the exception of elbow extension, for which Mmax
was 14.46.1Nm. The mean demands for elbow flexion, supination, and pronation were all between 2.9 and 5.0Nm.
The largest moment demands occurred at the shoulder.
Mmax values exceeded 11.5Nm in all shoulder movements
except internal rotation, which averaged only 3.42.8Nm.
Shoulder flexion had by far the largest demand, at
39.713.9Nm. This value was approximately double the next
largest demand, that of shoulder adduction.
WPSR Results
Mean WPSR values for the subject group ranged from
4.5%2.0% for elbow flexion to 66.5%20.3% for shoulder
flexion (table 3). Although the wrist joint had the lowest
demands (Mmax), the WPSR values for all 4 wrist motions
exceeded 21% (21.9%16.6% to 30.8%18.9%). At the elbow, extension, supination, and pronation WPSR values all
exceeded 34%. Elbow flexion WPSR was negligible. Shoulder
flexion WPSR averaged 66.5%20.3%, but values for abduction, adduction, extension, and external rotation of the shoulder
were also substantial, ranging between 22.5% and 33.9%. Only
the shoulder internal rotation WPSR was negligible.
DISCUSSION
Manual wheelchair propulsion has been implicated as a
major cause of both shoulder and wrist overuse injuries for
Table 3: Maximum Moment Requirement (Mmax) and WPSR
Values for Each of the Major Upper-Extremity Muscle Groups
During Wheelchair Propulsion Up a Ramp With a Slope of 2.9
Upper-Extremity Motion

Mmax (Nm)
Mean SD

WPSR (%)
Mean SD

Shoulder abduction
Shoulder adduction
Shoulder extension
Shoulder flexion
Shoulder external rotation
Shoulder internal rotation
Elbow extension
Elbow flexion
Elbow supination
Elbow pronation
Wrist radial deviation
Wrist ulnar deviation
Wrist extension
Wrist flexion

11.55.5
19.916.4
16.97.5
39.713.9
12.45.9
3.42.8
14.46.1
2.91.3
3.42.5
5.02.8
2.91.7
3.52.2
2.11.3
2.72.1

26.314.3
22.515.7
26.911.2
66.520.3
33.915.6
5.53.6
34.113.6
4.52.0
41.426.6
53.431.7
23.310.1
22.511.8
30.818.9
21.916.6

NOTE. Values are mean SD.

Arch Phys Med Rehabil Vol 85, July 2004

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UPPER-EXTREMITY DEMAND IN WHEELCHAIR PROPULSION, Sabick

those who rely on wheelchairs for mobility. Bayley et al1

questioned 94 independent male wheelchair users with paraplegia and found a 30% incidence of chronic shoulder pain
during transfers. The most common etiology of this pain was
chronic rotator cuff impingement syndrome with subacromial
bursitis. Bayley speculated that wheelchair propulsion contributed to the high rate of impingement in this patient group.
Gellman et al2 screened 84 patients with paraplegia for upperextremity complaints and found that 68% had some complaints
of upper-extremity pain. The most common complaint was
shoulder pain, reported by 30% of the subjects. Complaints
consistent with CTS were also common. Gellman also noted a
relationship between time since injury and upper-extremity
complaints. During the first 5 years after injury, 52% of patients complained of pain. The incidence of complaints increased to 62% by 10 years, to 72% by 15 years, and to 100%
by 20 years. Gellman2 concluded that upper-extremity pain was
a consequence of the increased stresses placed on the upper
extremities as a result of their being used for weight bearing
and mobility.
Strength Data
For the testing positions chosen to simulate wheelchair propulsion, this group of subjects generated the largest shoulder
moments in adduction and extension, followed by flexion and
internal rotation. Although the posture adopted in wheelchair
propulsion is apparently best suited for generating adduction
and extension moments at the shoulder, these are not important
moments in manual wheelchair propulsion. At the elbow, subjects generated greater torques in flexion than in extension,
even though the elbow extensors are considered a primary
muscle group involved in manual wheelchair propulsion.
Therefore, the posture adopted in manual wheelchair propulsion appears to be poorly suited for generating maximal joint
moments in the muscle groups that dominate propulsion.
The strength data we collected on subjects with paraplegia
are generally in agreement with other values in the literature.
Our mean shoulder external rotation torque of 37.1Nm compares favorably with that of Powers et al33 (43.1Nm), whereas
our internal rotation torque was much greater (57.4Nm vs
38.2Nm). Subjects with paraplegia in the Powers study had
higher external (43.1Nm) than internal (38.2Nm) rotation
torque values. This was attributed to compromised trunk stability during testing of this function, which resulted in a lack of
maximal isometric effort. In our protocol, the trunk was stabilized, which allowed our subjects to generate much higher
internal rotation torques.
Our shoulder abduction torque values were lower than those
reported by Powers33 (46.6Nm vs 65.7Nm). The difference in
torques between the studies is likely caused by the difference in
testing positions. Powers33 tested subjects with the elbow in
extension and the shoulder at 30 of abduction and 30 of
flexion, whereas our testing position had the elbow at 90 of
flexion and the shoulder in 40 of abduction in the scapular
plane. Our positions were designed specifically to simulate
upper-extremity positions obtained in wheelchair propulsion
and are therefore more relevant to the task of interest.
Mmax Data
The peak joint torques reported here generally agree with the
existing literature describing joint kinetics in wheelchair propulsion. As described in other studies, shoulder flexion and
elbow extension were the largest upper-extremity internal moments required during wheelchair propulsion.15,24,34,35 However, to our knowledge, no other studies provide kinetic data
for all the possible movements of the shoulder, elbow, and
Arch Phys Med Rehabil Vol 85, July 2004

wrist during propulsion up a ramp. Furthermore, methods used

by various investigators often differ, so direct comparison of
data is not always possible.
Two other studies24,34 have provided data for at least 3 of the
6 possible shoulder moments. Kulig et al24 simulated propulsion up an 8% incline (4.6) and calculated peak external
shoulder extension moments of approximately 31Nm. These
data correspond to our peak internal shoulder flexion moment
of 39.713.9Nm. Cooper et al34 calculated a peak internal
shoulder flexion moment of 42.9Nm in their group of subjects.
Other authors15,35 have reported peak shoulder flexion moments of between 30 and 35Nm. Therefore, our data are within
the range of these values. Our internal shoulder adduction
moment value of 19.9Nm agrees with that of Kulig,24 who
reported an external shoulder abduction moment of 21.3Nm.
Both our data and those of Kulig24 differ from those of Cooper,34 who found much smaller values. Our peak moment data
for shoulder external rotation (12.45.9Nm) are also similar to
those of Kulig24 (15.5Nm).
Peak elbow extension internal moments have been reported
between 10 and 21Nm.15,35 Our value of 14.4Nm is within this
range. To our knowledge, elbow flexion and forearm pronation
and supination moments have not been reported. Our data for
the wrist moments agree with those of Robertson et al,15 but
our values for wrist extension and ulnar deviation are much
lower than the values reported by Boninger et al.36 Joint moments are affected by both propulsion velocity and ramp grade,
so discrepancies are likely caused by differences in the test
conditions used for the various studies. In summary, our joint
moment data are in good agreement with the literature. As
described earlier, the shoulder flexors and elbow extensors are
the muscle groups that generate most of the propulsive moment
in manual wheelchair propulsion.
WPSR Data
Normalized indicators that account for both demand and
capacity are better predictors of injury than task demands
alone.23 Our study aims to eliminate a major weakness of other
analyses by considering the demand at the joint relative to its
capacity to produce a moment. For this reason, we have proposed the WPSR as a complementary means of evaluating
which joints are subjected to the greatest demands during
wheelchair propulsion. Several muscle groups had relatively
large WPSR values, even though their Mmax values were quite
small (fig 6). For instance, both the pronators and supinators of
the forearm are subject to a relatively large demand compared
with their strength, even though the moment demand was only
between 3 and 5Nm for both muscle groups. This is the first
study to suggest that the pronators and supinators may be
subject to high demands in wheelchair propulsion.
Even though the ramp slope was only 2.9, the demand on
the flexor muscles of the shoulder averaged 66.5% of capacity
in this group of experienced wheelchair users. Many of the
most common injuries at the shoulder are muscle and tendon
pathologies, such as rotator cuff tears, impingement, tendonitis,
bursitis,1,3,37,38 or bony disorders such as degenerative arthritis
and osteonecrosis.1,39-41 These injuries are to the muscular and
bony structures that generate or transmit loads across the joint.
The forces in muscles and tendons are proportional to the joint
moment. Increasing muscle forces also cause compression of
the articulating bones at a joint. Therefore, the structures most
commonly injured at the shoulderthe muscles, tendons, and
articulating surfacesare those most directly impacted by the
need to generate larger joint moments. The high WPSR for the
shoulder flexors when propelling a wheelchair up a ramp
suggests that high flexion moments must be generated. These

UPPER-EXTREMITY DEMAND IN WHEELCHAIR PROPULSION, Sabick

Fig 6. Comparison of mean WPSR and Mmax values. In some

cases, relatively low Mmax values correspond to relatively large
WPSR values, because of the limited capacity of the specific muscle
group to generate torque. Abbreviations: Dev, deviation; Ext, external; Int, internal; Rad, Radial; Rot, rotation.

high moments may negatively affect several shoulder structures.

The demand on the shoulder flexor muscles during wheelchair propulsion up a 20:1 ramp is large enough to lead to
muscle fatigue. In fatigue tests, when subjects have been asked
to perform intermittent submaximal isometric contractions at
50% of their initial maximal voluntary contraction (MVC)
level, the maximum force produced decreases by 50% in 4 to
5 minutes.42 In contrast, intermittent contractions at 30% of
MVC result in a 50% decrease in MVC force after approximately 30 minutes.43 Therefore, the 20% increase in required
force (from 30% of MVC to 50% of MVC) results in a
noticeable decrease in the time to fatigue (30min to 5min). In
a wheelchair-specific task, Rodgers et al16 found significant
differences in peak handrim force, radial/ulnar deviation range
of motion, and forward trunk lean after a fatiguing bout of
wheelchair exercise lasting only 6 minutes. Fatigue has also
been associated with higher risk of injury in other repetitive
multijoint tasks.44 The high demands on the shoulder flexors
during wheelchair propulsion up a ramp are within the range in
which fatigue could begin to affect both handrim and shoulder
kinetics that might lead to changes in movement patterns and
injury.
Although the shoulder flexors had the largest WPSR values,
several other muscle groups had WPSR values that suggest that
they are subject to fatigue as well. The pronators, supinators,
elbow extensors, and shoulder external rotators are all subject
to demands of 34% to 54% of their capacity in this task. As
discussed above, these data suggest that all 4 of these muscle
groups are at risk of fatigue during propulsion on longer ramps
or on level surfaces with high rolling resistance such as carpet.
These muscle groups have not been considered important in
wheelchair propulsion given their low Mmax values. For example, merely evaluating the maximal pronation moment required during wheelchair propulsion, the pronators would not
appear to be a concern because the demand is only 5.0Nm on
average. However, when coupled with the relatively low
strength of this muscle group, it becomes clear that the pronators are using a large portion of their capacitymore than
50%when ascending a 2.9 ramp.
At the wrist, all the WPSR values were below 31%, and all
the muscle groups controlling movement of the wrist joint
faced approximately equal demands (all had WPSRs between

1157

22% and 31%). Injuries to the wrist in manual wheelchair users

often involve median nerve dysfunction, such as CTS, rather
than the tendonitis and bursitis that are common in the shoulder.2,3,14 Pressure in the carpal tunnel is dependent on both
wrist kinematics (posture) and load on the tendons in the carpal
tunnel (joint moment).45 The WPSR is a good indicator of joint
moment demands but does not factor in wrist posture or compressive forces. Therefore, an understanding of the mechanism
of some types of joint dysfunctions requires information not
contained in the WPSR.
Our study highlights the differences between solely using
joint moments, or demand, to assess injury risk versus including both demand and capacity in the analysis. Ratios such as
the WPSR and JSR have the inherent attraction of making
intuitive sense, but their clinical utility is likely limited to
specific types of injuries that are most directly related to joint
moments.
Limitations
A strength of our research protocol is that subjects used their
own wheelchairs during the study. In this way, we avoided
changes in propulsion style that might have resulted when
wheelchair fit is altered. Our study is also unique in that
subjects did not use a treadmill or dynamometer to simulate
propulsion up a ramp. There is no research to prove that this
would affect any of the results. However, gait research has
shown differences in treadmill walking compared with overground walking with regard to both electromyographic activity
and ground reaction forces.46-48 Therefore, our study provides
novel data describing the biomechanics of ascending a realistic
ramp. However, these data are not directly applicable to wheelchair propulsion on level ground.
The major limitation of our study is the use of isometric
strength measurement as the denominator of the WPSR equation. Because the maximal force produced by a muscle varies
with both joint angle and velocity, the ideal method for determining demand as a function of capacity at any given time
during the propulsion cycle would be to take into account both
variables. In addition, a closed kinetic chain strength testing
method may be more appropriate. However, to collect this
information on a subject-by-subject basis is not feasible. Instead, we chose to use a simple model of strength measurement
based on single isometric measurements for each joint motion.
The positions in which strength data were collected were
carefully selected to represent positions obtained during manual wheelchair propulsion. Therefore, the data they provide is
a reasonable simplification of a very complicated muscle physiology and geometry, which has worked in ergonomics.23
The current analysis considers only joint moments and ignores the effects of joint shear and compression forces. Use of
WPSR, along with joint moment and joint force data, is likely
the best way to gain insight into the complicated biomechanics
of the upper-extremity joints during wheelchair propulsion.
CONCLUSIONS
In our experimental setup, shoulder flexion had the largest
WPSR (66.5%20.3%) value. Even on a relatively benign 2.9
ramp, several of the upper-extremity muscle groups required
moments that exceeded 30% of their capacity. The muscle
groups under the most demand when propelling up a ramp are
the shoulder flexors, forearm pronators, forearm supinators,
and elbow extensors. At steeper ramp grades, shoulder flexion
demand could easily reach the full capacity of the shoulder
flexor musculature to generate torque. WPSR values for the
wrist were relatively low.
Arch Phys Med Rehabil Vol 85, July 2004

1158

UPPER-EXTREMITY DEMAND IN WHEELCHAIR PROPULSION, Sabick

Our study presents a new measure of demand on the upper

extremity during wheelchair propulsion. Although based on
sound ergonomic research and making intuitive sense, the
validity and applicability of this measure for predicting the
likelihood of overuse injury in wheelchair propulsion remains
to be determined.
Acknowledgments: Special thanks to Diana Hansen for her help
with data collection and analysis.
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c. Motion Analysis Corp, 3617 Westwind Blvd, Santa Rosa, CA
95403.
d. The MathWorks Inc, 3 Apple Hill Dr, Natick, MA 01760-2098.
e. Cybex, Div of Lumex Inc, 2100 Smithtown Ave, Ronkonkoma, NY
11779-0903.

Arch Phys Med Rehabil Vol 85, July 2004