Maintaining arm health in wheelchair users: The need for updated guidelines

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Lynda Bennett
Original article: Sawatzy B, DiGiovine C, Berner T, Roesler T, Katte L. The Need for Updated Clinical Practice Guidelines for Preservation of Upper Extremities in Manual Wheelchair Users: A Position Paper. American Journal of Physical Medicine and Rehabilitation. 2014, October. Find the original article here.

Are you a manual wheelchair user (or do you know of someone who is)?

Ever wonder how your therapist keeps abreast of the latest advances in wheelchair technology and skills training? On their bookshelf (or computer), you’ll likely find guidelines published by medical organizations that provide relevant information based on research and professional consensus.

An example of such an organization is the Consortium for Spinal Cord Medicine. Its objective is to develop and publish clinical practice guidelines for spinal cord medicine. One of these guidelines is the “Preservation of Upper Limb Function Following SCI.” It addresses research on the alleviation and prevention of pain and injury in upper limbs often experienced by manual wheelchair users. Your therapist can use its recommendations when helping you choose and configure a wheelchair to match your requirements, and provide skills training to minimize potential pain and injury. This position paper recommends that these guidelines, last published in 2005, be updated to reflect recent research.

What did this investigation uncover? Evidence from research reviewed for this paper indicates that the key factors in preserving arm function include the way you push the wheelchair, the weight you push, the configuration and maintenance of your wheelchair, and skill training.

How was the research selected for review?

To identify research on the effect of manual wheelchair use on upper limbs, a systematic literature review of relevant articles published between 2004 and 2012 using the keyword ‘manual wheelchair,’ was performed using several medical databases. The authors selected relevant research from the 200+ articles that supported and further expanded observations included in the original SCI guidelines.

The statistics

Manual wheelchair users often experience upper extremity injury and pain. Estimates are that upwards of 70 to 100% of individuals will experience upper extremity pain using their wheelchair at some point in their lives. These consequences become more likely the longer one uses a wheelchair. The effects occur in three main locations:

  • Wrist and carpal tunnel 40-66%.
  • Elbow 5-16%.
  • Shoulder 30-60%.

Things YOU can do to minimize the strain

Maintain your chair

Wheelchair maintenance keeps the chair in optimum condition and is a key factor in preventing wheelchair breakdowns and safety hazards such as falls. It is important to follow the manufacturer’s instructions.

Wheelchair maintenance that is key in reducing strain on the upper limbs includes:

  • Maintaining tire air pressure: wheelchairs with tires inflated to 50% of the recommended tire pressure require 12% more effort to propel. It is important to note that tires lose up to 50% of their pressure within a month! Tire pressure also affects the performance of the rear wheel locks.
  • Cleaning front wheel castors: Castors clogged with hair, dust, and dirt can seize and increases the amount of friction and resistance to be overcome when pushing the chair.
  • Tightening wheelchair screws: Screws loosen with use over time. The more rigid the frame the more efficiently the chair will roll.
Improve your propelling technique

How do you move your chair? Studies show that the way you propel your chair significantly impacts the speed and distance you can travel. In addition, using recommended propulsion techniques helps minimize possible carpal tunnel injuries.

Figure 1 Stroke techniques from “The Need for Updated Clinical Practice Guidelines for Preservation of Upper Extremities in Manual Wheelchair Users: A Position Paper”


Did you know that the single loop method (SLOP) is the most efficient? Recent research indicates that using this method makes a difference in both speed and distance. Studies also indicate that it is better to use long smooth strokes, to lessen the jolt when pushing forward, and to allow the hand not being used to drift down below the hand rim.

What else is new in wheelchair research?

Weight, the type and position of the wheelchair’s rear wheels, the handrims, as well as the use of power assist technology are factors shown to reduce the incidence of shoulder/arm pain and injury.


There is a correlation between the weight of the wheelchair and incidence of arm/shoulder pain and injury. Using a lighter-weight chair gets you more speed and distance for the same effort. Maintaining an optimal body weight is also important. Any increase means more strength is required when shifting weight, transferring, and pushing which increases risk of pain or injury.

Rear Wheels

The position and type of rear wheels and tires and the type of handrims are additional factors. The position of the rear wheel affects the amount of force required to move the chair, the ease of reaching the handrims, and ability perform basic wheelchair skills.
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Consider the following findings when attempting to reduce the force required:

  • Position the rear wheels as far forward without affecting stability,
  • Select a frame that can be customized for the center of gravity and axle position,
  • Use air filled tires.

Think about the number of times you push your wheelchair each day. Each push requires an effort and, at times, great thrust. This can result in increased wrist pain and injury.

Wheelchair handrim ergometry

Recent research indicates that choosing ergonomic handrims (handrims that maximize the fit between the hand and the hand-rim) reduces pain and fatigue with extended use.

For those needing some help moving the chair, pushrim-activated power-assist wheels (PAPAWS) are an option for decreasing shoulder pain and increased distances. For more details on PAPAWS research, see here.

What’s new in training?

Will exercise and improved wheelchair skills improve your odds of pain- and injury-free shoulders and upper arms? Ask your therapist to develop a training program customized just for you.


Not only does exercise and weight training on a regular basis help prevent injury, it also helps reduce existing pain. Current guidelines suggest that “adults with a SCI should engage in (a) at least 20 min of moderate to vigorous intensity aerobic activity two times per week and (b) strength training exercises two times per week, consisting of three sets of 8-10 repetitions of each exercise for each major muscle group.”

Recent studies identify the most painful activities to be pushing oneself up ramps, overhead lifting, washing your back, pushing for 10 minutes or more, and loading the wheelchair into a car. Integrate flexibility exercises into your fitness programs to maintain normal range of motion in the upper body.

Wheelchair Skills

The position paper hypothesized that mastery of various wheelchair skills was another key to prevent pain and injury to shoulders, elbows and wrists. Just like any other skill, the safest and most biomechanically efficient techniques should be acquired and assessed to ensure competency. Use of a suitable method improves your safety and proficiency when performing various activities such as wheeling, performing transfers, or popping wheelies to mount curbs and other obstacles. In addition to avoiding injury, studies confirm that mastering these skills improves the odds of being employed and engaged in the community.

What were the conclusions of this study?

The position paper reveals a lag between recent research and current clinical practice. The original guidelines provide a framework for implementation but are limited to the research of the day. The current review of the research indicates support of the original guideline recommendations, but should be expanded to include areas such as wheelchair skills training. The authors also recommend that the scope of the original guidelines should be expanded to include not only those with SCI, but also other wheelchair users. With updated guidelines, your therapist will be able to provide you with better advice and training to minimize potential arm and shoulder pain or injury.

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3 thoughts on “Maintaining arm health in wheelchair users: The need for updated guidelines

  1. Thanks for the great summary Lynda, its a nice way to share knowledge in an accessible and consumable format. I wonder whether advocating for the SC approach, rather than SLOP, would facilitate a less-demanding recovery phase and easier coupling for the push phase?

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