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Shoulder Preservation: Functional Mobility versus Exercise

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As we continue our discussion on shoulder preservation one common question that comes up from therapists, end-users, and families frequently is: Should Propelling a Manual Wheelchair be Exercise?

This question comes in many forms. Often the therapist has the dilemma of worrying about the end-user being as independent as possible, the idea of maintaining the end-users’ function, and keeping in mind the costs associated with different product options. I have also heard a few therapists’ express concerns that if their client does not maintain an “active lifestyle” they could gain too much weight and not be able to fit into their system. The end-users and families usually tell me that they are concerned about the idea that “if they don’t use it, they will lose it”. This is a common statement that we as an industry made popular and unfortunately continues to be used every day.

 

 

Let’s now go back to the question: Should Propelling a Manual Wheelchair be Exercise? To answer this, we must start by defining what functional mobility is. Functional mobility is the ability for someone to move around in their environment. We ALL have to move around in our environments, whether it is our home or community, to be able to complete all of our daily activities. For an individual with a mobility impairment, this might mean that you need a walker, orthotics, or for this discussion, a manual wheelchair to move around in your environment.

Using myself as an example – for me to complete my daily activities I will move around by walking. This is not exercise for me. I need to be able to move around all day. Now imagine if I had to skip or run every time I moved. This would be not only exhausting, but also a lot of work for my body. I would likely not be able to complete all the tasks or participate in all the activities that I wanted to each day if I had to skip or run everywhere. Therefore, my options would be to either rely on someone else to help or I would simply not be able to participate.

Keeping this theory in mind, the same thought process should hold true for a person who uses a manual wheelchair as their means of mobility. If it is exercise to propel the chair, then you can become exhausted before the day even begins. You might not be able to participate in certain activities or engage in your community if you are exhausted because you are constantly “exercising”. What happens over a period of time to the shoulders? Are the shoulders meant to be exercising this many hours a day?

Functional Mobility should not be exercise! Functional mobility is a right for all of us, no matter what form of mobility we use. Pushing a wheelchair can be exercise, like a brisk walk or jogging. But remember, not all able-bodied people choose this as their exercise. Also, the upper limbs are more vulnerable to injury than lower limbs so “pushing for exercise” needs to be done in a way that does not present a danger of upper limb injury.

So, am I saying that no one should be in a manual wheelchair? NO! Instead, what we need to do is consider the individual, their environment, and their goals. Many end-users are able to propel their manual wheelchairs throughout the day, but some end-users may be working too hard to complete this mobility. In this case, we need to consider other options to help the end-user preserve their shoulders, reach their goals, and maintain their independence. Next week we will discuss one of these options – Power Assist!

Per Udden, the founder of Permobil, said it best:
“Every person has the right to have his or her disability compensated as far as possible by aids with the same technical standard as those we all use in our everyday lives.”

 

Rachel

Pneumatic Tyres Versus Solid Tyre: An End-Users Perspective

 

A critical part of a wheelchair, by definition, is the rear wheels and a critical part of the rear wheels is the type of tyre used. There are pros and cons for different tyre types. Rachel asked me to write about my experience with pneumatic and solid tyres, so here goes.

In my earlier years as a wheelchair user I used pneumatic tyres. One of the things that was a party spoiler was flat tyres. I had a bag that used to hang off the back of my chair, and it always had a spare tube and some tyre levers in it. But it was a hassle, for myself and my friends, and after a while I got sick of flat tyres. Plus, I had started travelling and just wanted the security and convenience of no flats. So, at some stage, I switched to solid tyres.

 

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I rolled on solid tyres for a lot of years. I got used to them, and they worked well. They were hard work when I needed to change them, but I felt secure with them. I was playing wheelchair basketball at the time and was using high pressure pneumatic tyres on my sports chair. The difference in roll resistance was significant, but for everyday use I just preferred the security that solids gave me. Then, about 12 years ago, a range of puncture resistant tyres became available in Australia. They claimed to be able to resist punctures from thumb tacks, and a few of my friends were using them so I decided to give them a go.

When I changed to these pneumatic tyres and pushed my chair again it was like a new chair, it was so much easier to push! I was really shocked at the difference. Research that compares pneumatic and solid tyres confirms the significant difference in performance between the two.

One paper which supports this is “The ergonomics of different tyres and tyre pressure during wheelchair propulsion” by BONITA J. SAWATZKY and Co. in Nov 2004 which found that “Choosing solid tyres instead of pneumatics puts those using the wheelchair at potential risk. Pneumatic tyres showed no statistically significant difference in rolling resistance until pressures had decreased to 50% of the recommended value. The performance of the solid tyre was worse than that of the pneumatic tyres even when they were inflated at 25% of the recommended pressure.”

I have been using them ever since, and they have proved to be sufficiently puncture resistant for my use. Even though they are more expensive than non-puncture resistant tyres they have proven to be longer lasting which makes them a better economical option. I have had only one puncture in all the time I have used them. Being brutally honest with you, I am not the role model wheelchair user when it comes to doing maintenance. For maintenance on pneumatic tyres I have a rechargeable cordless compressor which I use regularly to make sure there is sufficient air in the tyres. Changing tubes and tyres is not on my list of things I want to do on any day, besides which I suck at it. I have pinched more tubes than I would care to mention. So, any new tyres/tubes I need are now supplied and fitted by my local bike shop. If you live close to a good wheelchair dealer, they should also be able to do this. In saying this, for a vast number of wheelchair users, changing a tube and tyre is a quick and easy process.

Depending on a wheelchair user’s environment and daily activities, puncture resistant tyres may not be required. In this case economical tyres might be a better solution.
On the other hand, some people will require more puncture-proof resistance than any pneumatic tyre can provide. For example, people living in rural areas that come into contact with “three cornered jacks” or working in environments where there are nails and the like. In these cases, the compromise in performance can be justified and solid tyres may be the best option. And, for a lot of users, the absolute confidence solid tyres give them is worth the loss in performance.

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Some final thoughts, overall solid tyres are heavier than pneumatic tyres. There are different types of solid and pneumatic tyres and, in my experience, it has been worth spending a little more on good, quality tyres. The increased life of better-quality tyres usually means it is more economical in the long run. I would also not recommend solid inserts in pneumatic tyres. They are heavy and do not perform as well as other options.

Mal

 

The Weight is Not just Coming from the Frame

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We just finished last week’s blog talking about the differences between titanium and aluminium, one of those differences was the weight of each metal. In our continued discussion on shoulder preservation, we know that weight can be an important factor when propelling a manual wheelchair all day. Remember studies show that the average full-time manual wheelchair user completes 2,000 to 3,000 pushes every day! This is an enormous amount of work that we are asking the shoulders to complete. Therefore, weight is important. However, weight does not just come from the frame.

 

 

We can have the lightest wheelchair frame, but if we load it down with armrests, heavy cushions and backrests, solid tyres, etc… we just cancelled the weight we saved in choosing a lighter-weight frame. It is important we think about the components that we are putting on the wheelchair. With each component that we add onto the chair, we should ask ourselves, “What is the purpose/goal of this component?”. Let’s think about a few examples when it comes to an individual who is a full-time upper extremity propeller in a rigid manual wheelchair.

One of my favourite ways to decrease weight is to consider the armrests. What are the armrests doing for my client? Perhaps the end-user needs to have armrests to complete a functional activity, but more than often I see that the armrests are placed on the wheelchair for “comfort” reasons. How much weight does this comfort option add onto a wheelchair? It is not just the armrest itself, but also the large brackets required to mount these armrests to the wheelchair.

What about the wheels and tyres? This is another way that we can substantially increase the weight of a wheelchair. We often forget about how much a wheel and tyre can weigh. The position of the wheel and tyre is also a key. The further from the end-user the more impact the weight will have on propulsion. So, now if we think about the wheels and tyres and their location, we begin to understand the importance.

Does this mean that everyone who is a full-time manual wheelchair user should have pneumatic tyres and Spinergy Carbon Blade wheels? No, but it does mean that a discussion on goals and how this relates to the wheels and tyres is crucial. Therapists are often nervous about recommending pneumatic tyres for manual wheelchairs, but we want to help decrease this fear and will have a discussion in the upcoming blogs on the truths and myths of pneumatic tyres.

It is important to remember that even small changes can make a big difference. This should be considered in two ways. First, remember you can slowly start to work on decreasing the overall weight of the manual wheelchair, you don’t have to change the whole wheelchair in one day. This is also important for reason 2. Even the smallest changes could feel like a big change to the end-user. Everyone, whether you are the therapist, dealer, or end-user, has to remember that any change to the wheelchair will take time to get used to and may need further adjustments in the future.

As the therapist or end-user should you have to know all the different components available and their corresponding weight? No! You need to know your goals and/or the goals of the end-user. Then, it is the role of the dealer to help determine which products meet those goals and provide options. The dealer can help to discuss the options to decrease the overall weight of the wheelchair. The less weight on the chair, the less demand we place on the shoulders, right? This is absolutely true and should be considered for all individuals who are full-time upper extremity propellers, but if we don’t have the proper configuration, then even the lightest-weight wheelchair will be difficult to push.

Remember that if we all work together as a team, we can achieve the best results!

If you are interested in understanding more about this topic and how the weight distribution on the wheelchair matters, email me to set up your Materials Science for Manual Wheelchairs course.

Rachel

 

 

Materials Matters: Titanium verses Aluminium Manual Wheelchair Frames

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Malcolm’s perspective:
Right from the get-go let me say, I love titanium! From my first ride in a titanium chair some 15 years ago I remain convinced it is the best material on earth for wheelchairs. The ride in a titanium chair feels different, it has a dampening effect on bumps. When I got my first titanium chair my wife would often get surprised when she realised, I was beside her – she could hear my aluminium chairs coming as they went over the tiles and floorboards, but not the titanium chair. This was because of the vibration dampening. Apart from the “ride”, I love the fact it does not have to be powder coated, which means it does not chip, or look scratched and old. As well as that, titanium is strong – the strongest weight to strength ratio of any metal – which suits my lifestyle which involves lots of travel. After 15 years of regular plane trips I have confidence that when I arrive my chair will be good to go despite the rough handling it gets. That peace of mind is really important to me.

 

 

My chair is also ultra-light, especially with a non-folding back. With the configuration I have it is slightly under 8kg with the wheels on, about 4.5kgs with them off.
A couple of things to note, not all titanium is the same, so the type of titanium and the thickness of the tubing will impact on how the chair rides and how heavy it is. Also, my chair frame is made from titanium, but I have carbon fibre components such as side guard, wheels and backrest. Some of the parts are aluminium, such as front forks and camber clamps, so it is really a titanium frame with hybrid components.

Rachel’s thoughts:
Mal just gave a great insight into his preference. Now, let’s look at the materials and why Mal has preference for titanium versus aluminium. We have been able to learn a lot about the materials we use in manual wheelchairs through other industries, one of the big ones being the biking industry. We will start with aluminium. All types of aluminium have specific strength, low density, and resistance to corrosion. There are lots of different types of aluminium, but most manual wheelchairs are made of either 6000 or 7000 series aluminium. Many people believe that 7000 series is the best, just like how the iPhone 10 is better than the iPhone 8, but this is not true. The type that is best depends on how each manufacturer wants to use the aluminium. TiLite uses 6000 series as this allows for the aluminium to be weldable and for the greatest amount of customisability while still having a high strength. The 7000 series has a slightly higher tensile strength, but it is heat treated and therefore is harder to machine and less customisable. The difference in strengths of aluminium is minimal as compared to the difference in strength of aluminium to titanium. You can see the difference in the chart below. The chart on the left showers the ultimate strength of 6000 series aluminium, 7000 series aluminium, and then titanium. The chart on the right shows the strength-to-weight ratio.

 

 

Titanium has the highest strength to weight ratio of any metal on Earth. This gives the end-user a light weight and strong frame. Titanium is virtually immune to corrosion and is easily machined. From its ability to be easily machined and its strength to weight ratio, and vibration dampening properties, Titanium can allow us to achieve that ultimate fit. This ultimate fit along with the design of the frame of the chair leads to the optimal ride for our end-user. Although titanium has many benefits, it is a more expensive metal, and therefore the base price for a titanium frame will be more than an aluminium frame.
When deciding what type of material is right for you or your client, it is important to assess each person individually and consider the environments in which the chair will be used. It is also important to keep in mind the amount of time that will be spent in the wheelchair. We know that vibration has negative impacts on our health, and we know titanium through its material properties, design of the frame, and being easy to machine, will help to limit some of these vibrations, therefore providing the highest performance and ride for the end-user that is in the wheelchair throughout the day. We also know that strength is important as we want the frame to be able to withstand the environment that it is taken through. Finally, we want to think about the weight of the overall chair and how we can keep the weight low. This will help reduce the amount of work that we are asking the shoulders to do with every push. This is where are shoulder preservation comes back in! We want to make sure we can keep the chair as light as possible. This doesn’t just include the frame! We also need to think about what we are putting on this frame. All of the seating components, accessories, tyres, wheels, etc… have an impact on the weight of the wheelchair. Besides what goes on the wheelchair, we will also have to consider how the frame design impacts the ride, strength, and way that the wheelchair is built. We will continue this discussion next week.

Shoulder Preservation: An End-User Perspective – Mal’s Story

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In 1980, when I acquired my SCI, there was very little talk about preservation of shoulders. The focus was on strength, lots of weights and pushing. The adage “if you don’t use it you lose it” was strongly endorsed. In those days, I thought that shoulder pain was a good thing, it meant I had been working my shoulders and therefore strengthening them. In my mind it was “a badge of honour” to have sore shoulders. I didn’t know the difference between “good” pain and “bad” pain. In the early 1990s, I started playing competitive wheelchair basketball. Here I began to learn more about how to look after my shoulders – resistance bands, stretching, warming up, warming down, backwards pushing rotator cuff strengthening, etc… I also started handcycling and concentrated on the “pull” of the hand cranks to work the back of my shoulders. But, to tell the truth, my focus was so much on being competitive I often played with injuries, which I am sure has caused problems for me now. Hindsight is a great thing, and I wish I had of thought more about the long-term impact of the stresses I put on my shoulders, elbows, and wrists. Pain, loss of strength, loss of range and carpal tunnel syndrome are things I have experienced and continue to work against. At 39 years post injury, I am still mobile, and the past several years I have put into place strategies to maintain and improve the health of my upper limbs.

 

 

Apart from the obvious negative of pain, why is upper limb health so important to me? There are many reasons, but for the sake of this blog here are three of my main ones

Independence: A friend of mine often says that “if it goes without saying, it is worth saying”. My shoulders are fundamental to my independence. Being able to push my wheelchair, transfer, lift my chair in and out of the car, kayak, complete pressure reliefs – just about every activity of daily living (ADL) I do requires my shoulders.

Wellbeing: Being able to do all the things I can do independently has a huge impact on my        wellbeing. My SCI has cost me a lot of independence as it is, so I treasure every bit I have. Loss of independence is, quite frankly, depressing! As well as that, pain is a stressful thing, so minimising pain is really important.

Pressure Care: My shoulders are directly linked to my pressure care. In the past 39 years I have had only 2 pressure injuries which caused me to spend time in bed. One was post operation, the second was a stage 2 pressure injury caused by a bad transfer. The better my shoulders are the better my transfers are, and the less risk I have of a pressure injury.

So, as I race into my sixties and hopefully beyond, what are my strategies for looking after my shoulders? Here are some of the things I have done, and am now doing

My wheelchair is super light-weight and custom built around me. I have minimal adjustment and folding parts in my chair. After 39 years I pretty much know what I want out of my wheelchair, so a fixed back and fixed front to rear height is my preference. Even these simple things shave a noticeable amount of weight off my chair. I have the rear wheels as far forward as I feel safe with which makes it easier to push.

I restrict my pushing to areas that do not cause a lot of shoulder pain. I have been using a power assist device, the SmartDrive, for many years now and love it. I use it for any steep hills or really long pushes. I still push, but not as much and on less challenging slopes.

I have a set of strengthening and stretching exercises that I do regularly. Most of these involve resistance bands or a medicine ball, and are low weight with higher reps. The important thing is for me to concentrate on technique! They are exercises recommended by        my physiotherapist. As part of my NDIS Capacity Building, I have linked my goals of maintaining independence and function to the cost of the physiotherapist.

For cardio exercise, I rely on kayaking and handcycling. Both these activities allow me to focus on working the back of my shoulders, in the “pull” stroke.

I have been using an ergonomic hand rim for about 15 years now. These significantly improved my carpal tunnel issues. There are a number of these available, including the  Natural Fit™ and the Flex Rim™ (my favourite).

This is a little left field, but it has been an important change for me. Up until about 10 years ago I did not have wheel locks on my chair. With the improvement in design, specifically scissor locks, I finally decided to try them. It amazed me how much easier my transfers became!

 

The conversations I have with a lot of my peers these days centre around what we are doing to maintain shoulder strength and the impact long-term wheelchair propulsion is having on us now. If I could have a chat with my 20 year old self I would stress the importance of looking after his shoulders (not that he would have listened). In my mind the old adage of “use it or lose it” has been changed to “use it, don’t abuse it”. There is a lot of great Assistive Technology and resources to help wheelchair users maintain upper limb health, so why not take advantage of it all!

 

Malcolm Turnbull

 

Shoulder Preservation Part 4: The Recommendations for Shoulder Preservation with Manual Wheelchair Propulsion

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Let’s continue our conversation on propulsion with a manual wheelchair. Last week, we briefly looked at 7 of the recommendations based on clinical practice guidelines.  Today, we will begin our dive into those recommendations.  Let’s start at the top.

Provide manual wheelchair users with SCI a high-strength, fully customisable manual wheelchair made of the lightest possible material.

What does this mean?  We need to break this down into several parts.

High strength: This means that we need the chair frame to be strong enough for the individual using the chair and the environment the chair will encounter.  We can think about 3 of the popular manual wheelchair materials aluminium, titanium, and carbon fibre.

Each material has different properties and will give a different ride experience to the user. We must consider not only the material of the frame itself, but also how this frame is designed. The shape of the frame can greatly impact the ride experience for the user. Next week we will go into a discussion on these common frame materials and how we might choose one over the other based on each individual and their goals.

Fully Customisable: What does fully customisable mean? Does that mean that we can change the cushion and the backrest options? Or does that mean more?  Here is a great video where Josh Anderson discusses the importance of the fit of a wheelchair:

 

 

 

Think about fitting the wheelchair like a prosthetic.  This means fitting it across dimensions to get that perfect fit. If we think about this idea of prosthetics, we can understand the importance of the perfect fit. What happens to an individual when their prosthetic leg for example does not fit properly? Pain, skin breakdown, inefficient mobility, etc… Does this sound familiar for when we have a client with a manual wheelchair that is poorly fitted? We can all think about the hospital wheelchairs as an example. These wheelchairs are designed to fit everyone and for the hospital staff to get a client from point A to point B. Hopefully you have all attempted to propel this wheelchair and you remember how hard it is to even reach the wheels. This is an extreme example of a poor fit, but important for us to consider just how important the fit is for that full-time manual wheelchair user. We will dedicate another upcoming blog to getting this ultimate fit and what that truly means.

Lightest Material Possible: The key word there is possible. We must keep in mind the client’s environment and goals when deciding on the material. We will go into the weights of the main 3 materials next week but, what else do we need to consider? What if I choose the lightest material possible for the frame of the wheelchair for my client and then I give them every accessory they may every need on that chair?

It is crucial for us to not just consider the material of the frame, but to consider every component that goes onto that frame. This includes wheels, tyres, backrests, and armrests which is some of the areas that we often see a lot of weight being added to the wheelchair. Make sure when you are deciding on these components that you consider the client’s safety first along with their goals and then look into the weight of the different components.

 

 

 

 Rachel

Shoulder Preservation Part 3: The Recommendations for Shoulder Preservation with Manual Wheelchair Propulsion

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Did you know that the average number of pushes per day for a full-time manual wheelchair user is 2,000 to 3,000! Take a second and let this number sink in: 2,000 to 3,000 pushes every day. Now, go ahead and use that great technique we talked about last week and just take your arms and shoulders through 10 pushes. That was 10 pushes and without any bodyweight, weight of the wheelchair, friction of the chair across the ground, etc…. If we are not ourselves a wheelchair user, we cannot fully understand how our shoulders would feel propelling every day, but we can gain an understanding on the amount of work that the shoulders go through on a daily basis and what steps we can take to help in preserving the shoulder long term.

As a therapist, we cannot learn everything in our university, so it is important that we are always continuing the learning process and relying on researchers and experts in our field to guide us in our clinical practice. I often refer to our clinical best practice guidelines and today I want to talk about one of my favourites for shoulder preservation:
 
Preservation of upper limb function following spinal cord injury: A clinical practice guideline for health-care professionals. I highly recommend, if you haven’t already, downloading a copy. In reading the clinical practice guidelines there are 35 recommendations based on evidence-based research to promote preservation of the upper extremity. We will not cover all 35 recommendations, but over the next several blogs we will slowly be covering a few recommendations listed below:
 
1. Provide manual wheelchair users with SCI a high-strength, fully customisable manual wheelchair made of the lightest possible material.

2. Adjust the rear axle as far forward as possible without compromising the stability of the user.

3. Position the rear axle so that when the hand is placed at the top dead-centre position on the pushrim, the angle between the upper arm and forearm is between 100 and 120 degrees.

4. Educate the patient to:
    a. Use long, smooth strokes that limit high impacts on the pushrim.
    b. Allow the hand to drift down naturally, keeping it below the pushrim when not in actual contact with that part of               the wheelchair.

5. Promote an appropriate seated posture and stabilization relative to balance and stability needs.

6. Incorporate flexibility exercises into an overall fitness program sufficient to maintain normal glenohumeral motion and pectoral muscle mobility.

7. Incorporate resistance training as an integral part of an adult fitness program. The training should be individualized and progressive, should be of sufficient intensity to enhance strength and muscular endurance, and should provide stimulus to exercise all the major muscle groups to pain-free fatigue.
 
Hopefully as you read through all of these recommendations at least one or two makes sense already. Today, we are going to end with two videos from the extremely talented Madison de Rozario. Madison is an Australian Paralympic athlete and has helped create a few videos on the importance of shoulder health. In these videos you can see Madison touch on many of the above listed recommendations.
 

 

  

 

Next week, we will continue our discussion on shoulder preservation and deep dive into the recommendations.
Rachel

References:
Preservation of upper limb function following spinal cord injury: A clinical practice guideline for health-care professionals. J Spinal Cord Med. 2005; 28 5: 434–470.

 

Shoulder Prevention Part 2: The Shoulder During Manual Wheelchair Propulsion

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What happens when an individual propels a manual wheelchair?  What muscles are being activated? Does it change across the lifespan?  We will not cover this entire topic today but let’s begin with what is happening with the shoulder during manual wheelchair propulsion.

The first question we have to ask is WHY?  Why are we even talking about the shoulder during manual wheelchair propulsion?

Because the number of individuals who are full-time manual wheelchair users who will develop shoulder dysfunction and/or pain at some point in their life is staggering.  There is up to a 73% reported incidence of repetitive strain injury among full-time manual wheelchair propellers, with the shoulder being the most commonly reported site.  It is important for everyone, no matter if you are the therapist, carer, family, end-user, or supplier, to come together to provide the optimal equipment and outcome for the end-user to decrease their risk of shoulder dysfunction.

Starting at the very beginning, is understanding propulsion. Propulsion can be broken down into two phases: push phase and recovery phase.  In the photo below you can see the two phases highlighted.  The push phase first begins when the hand contacts the push rim and continues until the hand is released from the push rim.  The recovery phase occurs when the hand is first released until the hand makes first contact again with the push rim.

These are the two phases, but how the individual moves through these two phases can vary. Below is a photo showing a few different types of propulsion techniques. These techniques may be confusing to look at in a photo, so you can also click this link to watch a video discussing the optimal push technique.  This optimal technique, called the semi-circular technique, is discussed in the PVA clinical practice guideline for shoulder preservation referenced at the end. We will discuss propulsion technique further in the next blogs, but for today we will go back to the two phases of propulsion.  During each phase, different muscles will be required or activated.

 


 

 https://www.youtube.com/watch?v=BD9kp4u89Gc&feature=youtu.be

There are many studies looking into the activation of muscles during propulsion. This research can be challenging due to the inherent number of variables with testing. For today, we will look at a study by Mulroy and colleagues from 2004.  This study looked at individuals with spinal cord injuries and found the following muscles were activated during each phase:

Push Phase:

Anterior Deltoid, Pectoralis Major, Supraspinatus, Infraspinatus, Serratus Anterior, and Biceps

Recovering Phase:

Middle and Posterior Deltoid, Supraspinatus, Subscapularis, Middle Trapezius, and Triceps

Look at the number of muscles involved in propulsion!  What as a therapist, or end-user, are we doing to protect and strengthen the shoulder? We want to be sure that we are addressing the shoulder from the beginning whether this is through stretching, strengthening, positioning, modifications or education. This will vary for each individual based on their pain level, diagnosis, strength of each muscle, etc… It is best to have an individual program designed by a therapist to ensure that the end-user is safe.

Next week, we will continue to discuss the shoulder and manual wheelchair propulsion, propulsion technique, and look at some of the ways our end-users are taking care of their shoulders!

Rachel

Shoulder Preservation

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Part 1: Starting with a Foundation

As a therapist working with individuals with mobility impairments, did you ever think you would have to know so much about one joint? What joint am I talking about? The SHOULDER! I remember sitting in a classroom many years ago now, telling my classmate that I couldn’t wait to get past the orthopaedic semester and get to the neuro semester. I knew that I wanted to go on after my degree to work with individuals with spinal cord injuries, why did I need to sit through this whole semester on orthopaedics? Of course, after my clinical rotation on my neuro complex, I realised the importance of that semester on orthopaedics and the impact that orthopaedics had in every client that I saw. I often hear therapists tell me that they don’t really remember much from their university about the shoulder or that they “aren’t very good with the shoulder”. As a therapist, it can be challenging the amount of information that we are expected to know to a high degree, but understanding the why gives us the foundation to critically think and be able to examine a situation, client, or piece of equipment and formulate our treatment plan or product selection.

Over the next several weeks we are going to be discussing the shoulder.

 

 

The shoulder is the joint in the body I feel most passionate about, as many of our clients will be relying on their shoulders to now be their main means of mobility. It is crucial that we understand the shoulder from the inside out, building a foundation, as we want to preserve the strength and integrity of the shoulder for our clients for as long as possible. Today, let’s take a couple minutes to understand why the shoulder has such an impact on our clients.
First, we have to go way back to our anatomy class. We are going to mostly focus on the shoulder joint itself today, but we need to remember that the shoulder complex is comprised of 4 different joints that will all play a role into our client who relays on their shoulders for mobility. These 4 joints include: the glenohumeral joint, referred to as the shoulder joint; the acromioclavicular or AC joint; the scapulothoracic joint; and the sternoclavicular or SC joint. These 4 joints work together to provide the great amount of motion that the shoulder complex has.
We learned that the shoulder joint is a ball and socket joint just like the hip, but unlike the hip, the joint capsule is shallow. Look in the photo below. This shows the difference between the two joints. One of the joints is designed for stability, while the other is designed for mobility, mobility in this case meaning a wide range of motion. Do you know which one the shoulder is? That’s right! Hopefully you said the shoulder is designed for its wide range of motion. The problem is that this comes with a cost. The shoulder because it has such great mobility, is very unstable. There are ways that the shoulder joint gains some stability through the rotator cuff muscles, the ligaments, and the labrum. With these additional supports, do we get the stability in the shoulder we need for our full time manual wheelchair user?

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It is important that we consider the demands being placed on the shoulder by an individual with a mobility impairment. We have to consider the mobility impairment and the demand that the impairment places on the shoulders. For example, an individual who is a full-time manual wheelchair propeller versus a full-time power wheelchair user. While the individual who is using the manual wheelchair will have to rely on his/her shoulders for their propulsion, both individuals will have to reach overhead throughout their day. This is a key point that we will come back to in later blog sessions as overhead activity can greatly increase the risk of shoulder pain and dysfunction. We can decrease this risk in a power wheelchair with power seat functions when prescribed, but have we educated the client on the use of these power seat functions for shoulder preservation? Does the client understand the importance of limiting the amount of overhead activity throughout their day? How does this differ from an individual who utilises a manual wheelchair for mobility? Next week, we will begin with the demands of the shoulder for a manual wheelchair user.

Throughout the next several blogs, I hope you will continue to learn about the shoulder, its increased importance for clients with a mobility impairment, and the information that we need to continue to or start to consider when prescribing a manual or power wheelchair.

Rachel

 

The Importance of Our Support

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“Every person has the right to have his or her disability compensated as far as possible by aids with the same technical standard as those we all use in our everyday lives.” Dr. Per Uddén
Think about all of the different industries out there. Even if we make this smaller by just considering the industries within healthcare and technology. How many are there? How do they survive, but more importantly how do they thrive? What do I mean by thrive? Today, I am not talking about how much money the industry makes, but rather the advancement of the industry.
Look at some of the industries out there and the constant advancement they are achieving, such as the car industry. This is not just because of the financial backing that they have, but by the involvement from their customers and the industry as a whole. Every day I come to work, I remember the quote at the top. I am here to help in making this statement a reality, just as every one of you reading this blog has a part. Some of us may support this effort through hands-on work with the end-user, some may do this through providing the equipment, or you may be the individual receiving this equipment. No matter what our role is, we all have to work together to continue to push for more research, more innovation, and more advanced products.

One of the most important ways we can support our cause and our industry is through involvement! Involvement allows our voices to be heard, involvement allows for us to further our knowledge, and involvement allows for our industry to continue to grow, develop, and improve. One of the best ways we can get involved is through industry wide conferences, events, and expos. Some of these events allow us the opportunity whether you are an end-user, parent, carer, therapist, supplier, or manufacturer to meet under one roof with the same main objective – for an individual, regardless of a disability, to live their life to the same technical standard.

I am discussing this today as we have a fantastic opportunity to support our industry next week in Sydney with the ATSA Independent Living Expo. This is the perfect example of an expo that provides the platform to move our industry forward. One of my favourite parts of this type of expo are the presentations. This is an opportunity for end-users, family, therapists to all come and learn the most updated research, current affairs within the industry, and the opportunity to ask questions! The more we as a community support, not only the expo, but the presentations through attendance we push the presenters to provide the most up to date, applicable, research driven information.

 


The most important advice I can give is to remember to ask questions. Whether it is in the presentations or on the floor of the expo, it is important for everyone to ask questions. Questions allow learning and development. Questions are what push us as an industry to advance in our technology, research, and innovation. If we never asked questions, we would just become complacent. It can be intimidating to walk up to a manufacturer, supplier, etc… in the expo, but here are a few ideas to get the conversation started:
Do you have any new products this year? Why were these products designed? What makes them unique? How can they assist in the improvement in the quality of life of the end-user?
It isn’t just about asking questions either. Try it out! Don’t be afraid to get hands on! You can’t always try out every product but ask if you can. One of the best ways we can learn is through trialling. Whether it is sitting on a cushion, driving a power wheelchair, or trying out a robotic arm. Make sure you are keeping safety at the front of this exploration but have fun learning!
Remember that the only way for our industry to continue to develop new products that will better support the end-users, is to create a reason for that continued development, creating the intention for each new design. One of the biggest pushes in this comes from all of you! Asking the questions, providing feedback, and letting the manufacturers know what it is that you need and want. In many industries the customer and the manufacturer are seen as two separate groups, fighting against each other. I want to charge us as an industry to continue to work together to achieve our common goal. One of the greatest ways that we can do this is through events such as the ATSA Independent Living Expo. Whether you are a therapist coming to attend the presentations and learn, an end-user coming to see the products first hand, or a family member just a little over-whelmed and wanting some information – ATSA’s Independent Living Expo is for you!
Here are the dates below for this expo and a few other upcoming expos in Australia and New Zealand. Feel free to email me or post below with other expos going on in your area. I will be at all the events listed below, so be sure to stop by and say hello.

 

ATSA Independent Living Expo

https://www.atsaindependentlivingexpo.com.au

Sydney, May 8-9
Brisbane, May 15-16
Canberra, August 27-28

 

 ATSNZ Expo– Assistive Technology Suppliers New Zealand

 https://www.atsnzexpo.co.nz/

 Auckland, May 23

 

 Source Kids Disability Expo

https://www.sourcekids.com.au/expo/expo-brisbane-2019

Brisbane, July 5-6

 

Oceania Seating Symposium (OSS)

http://www.cmnzl.co.nz/oceania-seating-symposium/

Melbourne, November 12-14