Archives of Physical Medicine and Rehabilitation

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Archives of Physical Medicine and Rehabilitation 2014;95:699-704

ORIGINAL ARTICLE

Relationship Between Shoulder Pain and Kinetic and

Temporal-Spatial Variability in Wheelchair Users
Ian M. Rice, PhD,a Chandrasekaran Jayaraman, MS,b Elizabeth T. Hsiao-Wecksler, PhD,c
Jacob J. Sosnoff, PhDa
From the aDepartments of Kinesiology and Community Health, bIndustrial Enterprise Systems Engineering, and cMechanical Sciences and
Engineering, University of Illinois at Urbana-Champaign, Urbana, IL.

Abstract
Objective: To examine intra-individual variability of kinetic and temporal-spatial parameters of wheelchair propulsion as a function of shoulder
pain in manual wheelchair users (MWUs).
Design: Cohort.
Setting: University research laboratory.
Participants: Adults with physical disabilities (NZ26) who use a manual wheelchair for mobility full time (>80% ambulation).
Interventions: Participants propelled their own wheelchairs with force-sensing wheels at a steady-state pace on a dynamometer at 3 speeds (self-
selected, 0.7m/s, 1.1m/s) for 3 minutes. Temporal-spatial and kinetic data were recorded unilaterally at the hand rim.
Main Outcome Measures: Shoulder pain was quantified with the Wheelchair Users Shoulder Pain Index. Intra-individual mean, SD, and co-
efficient of variation (CVZmean/SD) with kinetic and temporal-spatial metrics were determined at the handrim.
Results: There were no differences in mean kinetic and temporal-spatial metrics as a function of pain group (P values >.016). However, in-
dividuals with pain displayed less relative variability (CV) in peak resultant force and push time than pain-free individuals (P<.016).
Conclusions: Shoulder pain had no influence on mean kinetic and temporal-spatial propulsion variables at the handrim; however, group dif-
ferences were found in relative variability. These results suggest that intra-individual variability analysis is sensitive to pain. We propose that
variability analysis may offer an approach for earlier identification of MWUs at risk for developing shoulder pain.
Archives of Physical Medicine and Rehabilitation 2014;95:699-704
ª 2014 by the American Congress of Rehabilitation Medicine

There are an estimated 2 million manual wheelchair users (MWUs) demographic features such as years of wheelchair use, sex, weight,
in the United States.1 Although manual wheelchair propulsion offers functional injury level, and age, have been investigated.5,9-12
numerous benefits, it is often associated with upper extremity pain Although the shoulder’s vulnerability to propulsion has been
and injury that can severely impact function and independence.2-4 well established, researchers have not found clear distinctions be-
Because of the adverse consequences of upper extremity pain in tween the technique of MWUs with and without shoulder pain.7,8
MWUs, a large amount of research has focused on determining While larger forces and moments have been related to measures
factors related to upper extremity pain. For instance, propulsion of shoulder pathology, it remains unclear how pain affects biome-
parameters including contact angle, stroke frequency, and rate of chanics at the handrim. Historically, propulsion biomechanics
rise and magnitude of peak forces and moments,2-8 as well as research related to upper limb pain and injury has focused almost
entirely on the average kinetic and temporal-spatial metrics.7,8
There is increasing evidence that variations in movement within
Presented to the Rehabilitation Engineering and Assistive Technology Society of North
an individual provide valuable information concerning underlying
America, 2012 motor control and pathology.13,14 It is maintained that movement
Supported in part by the National Institutes of Health (grant no. 1R21HD066129-01A1). variability within limits is a normal characteristic of healthy neu-
No commercial party having a direct financial interest in the results of the research supporting
this article has conferred or will confer a benefit on the authors or on any organization with which
romotor systems and affords greater adaptability to environmental
the authors are associated. stressors.14,15 Variability outside the normal range is indicative of

0003-9993/14/$36 - see front matter ª 2014 by the American Congress of Rehabilitation Medicine
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700 I.M. Rice et al

pathology, and individuals experiencing pain are known to have Data collection
distinct variability profiles during various motor tasks.14,16 For
example a relation between kinematic and temporal variability and Participants’ own wheelchairs were fitted bilaterally with 25-in-
skeletal injury has been demonstrated in ambulatory individuals diameter SmartWheels22,23,a and placed on a single drum dyna-
with knee,17 shoulder,18 and low back pain.19 In all of these cases, mometer with a fly wheel and tie-down system. The participants
individuals with pain demonstrated less variability than their were asked to propel at constant speeds of 1.1m/s (fast) and 0.7m/s
healthy peers. It has been suggested that decreased motor variability (slow) and at a self-selected speed for 3 minutes. Perceived
results in the development of musculoskeletal disorders and exertion was quantified after each trial with the Borg perceived
injury.14,20 exertion scale. Full rest and recovery were provided between tri-
To our knowledge, this is the first published investigation of als. The sequence of speeds was randomly selected for each
variability in wheelchair propulsion at the handrim as a function of subject, and a speedometer placed in front of each participant was
shoulder pain. The study of movement variation during wheelchair used to provide real-time visual feedback during propulsion. In
propulsion may have practical implications both clinically and addition, subjects were given time to acclimate to the dyna-
scientifically because it is a parameter that is easily captured with mometer and propulsion speed before each trial.
an instrumented wheel and may be modifiable through a combi- Kinetic and temporal-spatial data were collected and streamed
nation of technique training or wheelchair configuration. wirelessly from the right-side SmartWheel for each trial at 100Hz
The purpose of this study was to determine whether there are once a steady-state velocity was reached. A push cycle was
differences in intra-individual (eg, within the individual) vari- defined as the period when the moment applied to the handrim
ability in kinetic and timing propulsion parameters as a function of was more than 0.8Nm for more than 150 milliseconds.
shoulder pain in full-time MWUs. Based on the extant literature, The WUSPI, a reliable and valid 15-item questionnaire, was
we predicted that MWUs with shoulder pain would demonstrate used to quantify the presence of pain in all participants.24,25 It
less kinetic and temporal-spatial variability at the handrim during measures how shoulder pain has interfered with daily activities,
propulsion compared with those without pain. such as transferring, wheeling, and self-care. Each item is scored
from 0 to 10, with 10 representing shoulder pain that has
completely interfered with the activity during the past week.
Methods Adding the scores for each item answered derives the total score.
Total scores range from 0 (no pain) to 150 (maximum limitations
Participants caused by pain).
Ratings of perceived exertion (RPEs) were recorded immedi-
Twenty-six individuals (10 women, 16 men) from the Urbana- ately after each propulsion trial using the Borg scale as an index of
Champaign community volunteered and provided informed con- perceived physiological stress.26 All participants received detailed
sent before participation in this study. All the participants were instructions about the use of the scale and were given examples of
MWUs who used a wheelchair as their primary means of ambu- how they might rate differentiated RPE.
lation for more than 1 year and were between 18 and 64 years of
age. People were excluded from participation if they had upper Data reduction
limb pain that prohibited them from propelling a manual wheel-
chair. The wheelchair users’ diagnoses include spinal cord injury Peak resultant force, peak rate of rise of resultant force (N/s), contact
(T8 and below, nZ12), spina bifida (nZ8), cerebral palsy (nZ1), angle (degrees), stroke frequency (strokes/s), and push time (s) were
spinal cyst (nZ2), arthrogryposis (nZ1), and amputation (nZ2). calculated with a custom MATLABb program for each trial. Peak
Participants were separated into a pain group or a no-pain group resultant force is the maximum total force applied to the handrim per
based on self-report of shoulder pain. They were asked whether stroke cycle, while peak rate of rise of resultant force is the
they were currently experiencing shoulder pain, and rated their maximum instantaneous loading rate at the handrim.5,22,27 These
current level of shoulder pain with a 10-cm visual analog scale21 variables were selected because of their association with the
of 0 (no pain) to 10 (high pain). development of upper extremity pain and injury.2,5,6
All propulsion outcome measures were formulated as mean
(X), intra-individual SD, and coefficient of variation (CV).
Protocol Figure 1 illustrates the peak resultant force at the handrim over

All experimentation was approved by the local institutional review

board. On arrival to the laboratory, participants received an Table 1 Demographic characteristics
explanation of the experimental procedures and were provided the
Characteristics Pain No Pain
opportunity to ask questions. After all questions were answered,
participants were asked to provide informed consent. They then Subjects 13 13
provided demographic information and completed the Wheelchair Age (y) 28.5
12.3 20.9
4.9
Users Shoulder Pain Index (WUSPI) (table 1). Sex (M/F) 8/5 8/5
Weight (kg) 73.8
25.2 62.8
14.3
Wheelchair use (y) 15.3
11.4 12.9
5.3
List of abbreviations:
WUSPI score 22.3
21.4* 3.9
5.0
CV coefficient of variation
MWU manual wheelchair user NOTE. Values are n or mean
SD.
RPE rating of perceived exertion Abbreviations: F, female; M, male.
WUSPI Wheelchair Users Shoulder Pain Index * Significant difference, between groups (pain/no pain) (P<.012).

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Variability in manual wheelchair propulsion 701

3 minutes of propulsion at fast speed in a representative partici- Kinetic and temporal-spatial propulsion outcomes
pant without shoulder pain. It is clear in the figure that there are
slight fluctuations in peak resultant force and timing of each push. Multivariate report
This push-to-push variation within an individual was quantified The mixed-design multivariate analysis of variance showed a main
with SD (absolute amount of variation) and CV (relative variation) effect for pain (Pillai-Bartlett traceZ.376, F15,61Z2.15, PZ.01,
(see fig 1). h2Z.34) and speed (Pillai-Bartlett traceZ.828, F30,124Z2.91,
P<.001, h2Z.41).
Statistical analysis
Average kinetic and temporal-spatial metrics
Statistical analyses were conducted using SPSS version 21 for Win- Replicating previous work, average kinetic and temporal-spatial
dows.c All data were examined for normality; appropriate statistical performance variables did not differ between those with and
analyses were then used as needed. Differences in demographic without pain (P>.016) (table 3). As expected, stroke frequency
characteristics were compared between groups. Continuous indepen- increased with faster propulsion speeds, while push time
dent variables (age, years of wheelchair use, weight, WUSPI score) decreased ([F2,75Z9.8, P<.001, h2Z.29] and [F2,75Z23.2,
were compared using a Student t test with a Bonferroni correction P<.001, h2Z.383], respectively) (table 4).
(PZ.0125). The mean, SD, and CV of the dependent variables (peak
resultant force, peak rate of rise of resultant force, contact angle, stroke Absolute intravariation (SD) propulsion variables
frequency, push time) were compared using a 2-by-3 mixed-model Absolute intra-SD in peak resultant force was significantly
multivariate analysis of variance with the between-subject factor of different between pain groups, with those with pain being less
group (pain/no pain) and the within-subject factor of speed (slow, self- variable (F1,75Z7.5, PZ.007, h2Z.092) (see table 3). Statistically
select, fast). Significance was set to .016 (.05/3) based on the inclusion significant differences in absolute SD were also found based on
of mean, SD, and CV into the multivariate analysis of variance. A speed condition (P<.016). Push time became less variable with
Bonferroni post hoc test was applied to further analyze significant speed, while stroke frequency became more variable
main effects where appropriate. ([F2,75Z22.8, P<.001, h2Z.379] and [F2,75Z4.7, PZ.01,
h2Z.11], respectively) (see table 4).

Results Relative intravariation (CV) propulsion variables

CV (%) was statistically significant as a function of pain group and
Participant demographics speed condition (fig 2; see tables 3 and 4). For example, individuals
who reported pain displayed a reduced CV compared with those
The pain group had a higher total WUSPI score than the no-pain without pain in overall push time, peak resultant force, and contact
group (PZ.006) (see table 1). angle (approaching significance) ([F1,75Z7.4, PZ.008, h2Z.09],
[F1,75Z18.0, P<.001, h2Z.19], and [F1,75Z5.6, PZ.02, h2Z.06],
Velocity and perceived exertion respectively) (see fig 2, see table 3). All participants, regardless of
pain status, displayed decreased CV with increased speed for stroke
frequency, push time (approaching significance), and peak rate of
All participants maintained speeds very close to the targets pro-
rise of resultant force (approaching significance) ([F2,75Z12.8,
vided in real time. Actual propulsion speed differences between
P<.001, h2Z.25], [F2,75Z4.1, PZ.02, h2Z.09], and [F1,75Z4.2,
groups (pain/no pain) were not significantly different (P>.05).
PZ.017, h2Z.10], respectively) (see table 4).
Perceived exertion scores were low (20%e30% effort) for all
speed conditions and not significantly different between groups
(P>.05). On average, the magnitude of self-selected speeds fell in Discussion
between the slow and fast conditions for both groups (table 2).
We hypothesized that MWUs experiencing pain would propel
with less variable kinetic and temporal-spatial propulsion outcome
measures than those without pain. Consistent with our hypothesis,
MWUs with pain displayed decreased CV in kinetic and temporal-
spatial variables (see table 3). These results provide preliminary
evidence that CV may serve as a unique marker of shoulder pain.

Table 2 Actual speeds with corresponding perceived exertion

Group
Pain No Pain
Speed Actual Actual
Condition Speed (m/s) Borg Speed (m/s) Borg
Slow (0.7m/s) 0.72
.03 7.8
2.5 0.72
.03 7.6
2.0
Self-selected 0.92
.14 7.9
2.3 0.93
0.23 8.1
1.8
Fig 1 Representative peak force data and derivation of propulsion Fast (1.1m/s) 1.12
.04 8.0
1.9 1.14
0.05 8.6
2.4
outcome variables. Abbreviations: F, force; sd, standard deviation;
NOTE. Values are mean
SD.
X,mean.

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702 I.M. Rice et al

Table 3 Performance variables as function of pain status across speed conditions

Mean SD CV
Performance Variables Pain No Pain Pain No Pain Pain No Pain
Peak Fr (N) 62.6
3.1 61.4
3.0 5.7
0.3* 7.0
0.3* 9.2
0.4* 11.9
0.4*
Peak ror Fr (N/s) 590.5
58.8 587.2
56.7 112.4
9.1 136.2
8.8 22.9
1.3 24.5
1.3
CA (deg) 103.1
3.1 97.3
3.0 5.3
0.2 5.9
0.2 5.2
0.3y 6.5
0.3y
SF (strokes/s) 0.7
.02 0.7
.02 0.1
.003 0.1
.003 17.2
0.3 17.0
0.3
PT (s) 0.6
.02 0.5
.02 0.04
.002 0.04
.002 6.3
0.3* 7.5
0.3*
NOTE. Values are mean
SE, collapsed for speed (slow, self-selected, fast). Mean, traditional “mean” performance variable; SD, within-subject SD (s);
CV, expressed as % (s/m * 100).
Abbrevations: CA, contact angle; Fr, resultant force; PT, push time; ror Fr, rate of rise of resultant force; SF, stroke frequency.
* Significant difference between groups (pain/no pain) (P<.016).
y
Approaching significance between groups (pain/no pain) (P<.05).

In the present study, persons reporting pain displayed reduced particular tissue. In fact, more variable motor strategies have been
relative variability (CV) in both temporal-spatial and kinetic proposed and supported as a protective factor against the devel-
propulsion metrics; however, no differences were observed based opment of work-related musculoskeletal disorders.18,28 The most
on average values. Furthermore, differences in CV based on pain frequently suggested intervention against musculoskeletal disor-
were noted across all speeds, including those self-selected. Spe- ders caused by repetitive work is to decrease its similaritydthat is,
cifically, individuals with pain displayed reduced variability in create more “variation” in biomechanical exposure.29 Importantly,
peak resultant force production and time spent in propulsion. wheelchair propulsion, with a stroke occurring approximately
Although novel to wheelchair propulsion research, these obser- once per second,30 far exceeds what most studies consider a re-
vations are consistent with several reports14,20 of movement tasks petitive task.31,32
in which a variety of long-term pain conditions have been asso- The average kinetic and temporal-spatial propulsion outcome
ciated with reduced motor variability. measures obtained in the present study are fully consistent with
Because the current study is cross-sectional, it is not possible the extant wheelchair propulsion literature.2,5,7,8 Specifically, the
to suggest a definitive directional association between peak force average values observed here were not only comparable in
variability and shoulder pain; however, 2 possible explanations magnitude but similar in the sense that there were no observable
warrant discussion. It is possible that the presence of shoulder pain differences between the average kinetic and temporal-spatial
in our subjects caused them to constrain their movements to avoid values of MWUs with and without pain. In fact, previous
pain, resulting in reduced peak force variability. Alternatively, it is studies7,8 have found that pain did not alter the way a person
possible that reduced variability is a sign of an underlying propels a wheelchair. The authors suggested that propulsion
mechanism that led to the development of pain by demanding biomechanics contribute to pathology, rather than pain or pa-
relatively constant loading at the handrim. thology influencing propulsion style.7,8 While it is difficult to
The variability overuse hypothesis maintains that a lack of make direct comparisons to this work because of methodological
variation results in insufficient time to adapt or heal.16 If move- differences, our findings provide preliminary evidence that dif-
ments are repeated without variation, it is believed that the same ferences in kinetic and temporal-spatial outcome measures may
soft tissues receive large doses of damaging force application. exist when an intra-individual variability analysis approach is
Increased movement variability would therefore modify tissue instituted.
loads from repetition to repetition, distribute stresses more equally Statistically significant relationships were found in outcome
among tissues, and thus reduce the cumulative load on any measures based on changes in propulsion speed. For example, our

Table 4 Performance variables as a function of speed across pain groups

Performance Mean SD CV
Variables Slow SS Fast Slow SS Fast Slow SS Fast
Peak Fr (N) 56.2
3.7 62.2
3.7 67.5
3.7 5.8
0.4 6.5
0.4 6.8
0.4 10.6
0.5 10.8
0.5 10.3
0.5
Peak ror 482.4
70.8 600.1
70.8 683.1
70.8 118.2
11.0 122.2
11.0 132.6
11.0 27.5
1.6* 22.6
1.6* 21.0
1.6*
Fr (N/s)
CA (deg) 99.7
3.8 99.2
3.8 101.6
3.8 6.1
0.3 5.5
0.3 5.3
0.3 6.5
0.4 5.8
0.4 5.3
0.4
SF (strokes/s) 0.6
.03y 0.7
.03y 0.8
.03y 0.11
.004y 0.12
.004y 0.13
.004y 18.4
0.3y 17.2
0.3y 15.7
0.3y
PT (s) 0.7
.02y 0.5
.02y 0.4
.02y 0.05
.003y 0.04
.003y 0.03
.003y 7.7
0.3* 6.7
0.3* 6.2
0.3*
NOTE. Values are mean
SE, collapsed for speed (slow, self-selected, fast). Mean, traditional “mean” performance variable; SD, within-subject SD (s);
CV, expressed as % (s/m * 100).
Abbrevations: CA, contact angle; Fr, resultant force; PT, push time; ror Fr, rate of rise of resultant force; SF, stroke frequency; SS, self-selected.
* Approaching significance based on the main effect of speed (P<.05).
y
Significant difference based on the main effect of speed (P<.016).

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Variability in manual wheelchair propulsion 703

support to variability providing a means for earlier identification

of individuals at risk for developing shoulder pain and associated
adverse outcomes.
When viewed in combination with previous research, our re-
sults suggest that the study of variability has great potential and
should be applied to wheelchair user propulsions. Although this
pilot study was a first step, it suggests that kinetic and temporal-
spatial measures of intra-individual stroke variability at the
handrim may be more sensitive to stroke differences caused by
pain than traditional biomechanical measures where group dif-
ferences are not detectable.

Study limitations

A major limitation of the current study was the lack of measures

used to assess propulsion technique. Only kinetic and temporal-
spatial measures at the handrim were quantified, which do not
fully constitute an individual’s propulsion biomechanics. Future
work should incorporate measures of motion analysis and muscle
activity to further characterize propulsion biomechanics. Another
limitation of this study was that propulsion occurred on a dyna-
Fig 2 CV group differences. )Significant difference between groups mometer at submaximal levels. Because the study was designed to
(pain/no pain) (P<.05). AApproaching significance between groups capture naturally occurring variability caused by pain, it was
(pain/no pain) (P<.10). Abbreviations: CA, contact angle (angle critical to minimize the occurrence of fatigue because it has been
along the arc of the handrim); peakFr, peak resultant force at the shown to cause distinct variability patterns.34,35 While it is
handrim; PT, push time (time hand is in contact with handrim). possible some subjects were more challenged than others, the
dynamometer and visual speed feedback system allowed re-
subjects’ average variables changed similarly to previous studies searchers to control subjects’ exertion levels. The extent to which
where increased speeds corresponded to higher forces and reduced the same differences in CV caused by pain or changes in speed
push time. However, SD and CV also changed significantly with translate to more challenging propulsion scenarios is unknown and
speed. For example, all subjects independent of pain displayed warrants further investigation. This study also had a relatively
decreased CV with increased speed for temporal-spatial variables. small sample size; however, we were still able to find differences
Similar relationships were observed for SD; however, the SD of caused by pain. In addition, although our subjects had a diverse
stroke frequency increased with increasing speed. Although novel range of disabilities, these results may not be generalizable to all
to the study of propulsion, these findings are consistent with MWUs. Future work performed on a larger, more diverse group of
human space-time accuracy principles where spatial error has MWUs is needed to fully characterize the range of variability that
been shown to increase as a function of movement time, and constitutes healthy motor adaptation in MWUs.
temporal error is reduced through reductions of move-
ment speed.33 Conclusions
While the CV and SD of timing variables tended to decrease
with speed, participants reported extremely low RPE values
The mean wheelchair propulsion values of peak force and push
throughout, suggesting that propulsion conditions such as speed
time were not different between pain groups. However, the vari-
and rolling resistance were not overly challenging. In addition,
ability of these biomechanical measures of wheelchair propulsion
this study examined these measures in long-term wheelchair users
was lower in wheelchair users with shoulder pain. Future work is
using their own personal wheelchairs. Additionally, all mean
needed to determine whether relative variability analysis will offer
propulsion values were recorded based on 3 minutes of steady-
an approach of earlier identification of MWUs at risk for devel-
state propulsion or up to 190 strokes, which is a considerably
oping shoulder pain and upper limb musculoskeletal disorders.
longer recording period than in most studies,2,5,6 where re-
searchers typically record the mean of 5 to 10 strokes.
Selection bias is an inherent challenge to researchers studying Suppliers
wheelchair users experiencing pain.7 Although participants report
pain, the experience of pain is subjective and affects individuals a. Three Rivers Holdings, LLC, 1826 W Broadway Rd, Ste 43,
differently. Historically, if pain is severe enough, individuals are Mesa, AZ 85202.
typically excluded from participation, do not volunteer, have b. The MathWorks, Inc, 3 Apple Hill Dr, Natick, MA 01760-
already switched to power mobility, or may have permanently 2098.
modified their technique to avoid pain. The individuals with pain c. SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.
in this study overall reported relatively low WUSPI scores that
some might consider negligible. However, this could be viewed as Keywords
a study strength. Despite low pain levels, kinetic and temporal-
spatial stroke differences were still detectable, which lends Rehabilitation; Shoulder; Wheelchairs

[Link]
704 I.M. Rice et al

Corresponding author 15. Stergiou N, Harbourne R, Cavanaugh J. Optimal movement vari-

ability: a new theoretical perspective for neurologic physical therapy. J
Neurol Phys Ther 2006;30:120-9.
Jacob J. Sosnoff, PhD, Department of Kinesiology and Commu-
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nity Health, College of Applied Health Sciences, University of sports biomechanists? Sports Biomech 2007;6:224-43.
Illinois at Urbana-Champaign, Freer Hall, 906 S Goodwin Ave, 17. Hamill J, van Emmerik RE, Heiderscheit BC, Li L. A dynamical
Urbana, IL 61801. E-mail address: jsosnoff@[Link]. systems approach to lower extremity running injuries. Clin Biomech
(Bristol, Avon) 1999;14:297-308.
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