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Wheelchair propulsion biomechanics and wheelers' quality of life: An

exploratory review

Article  in  Disability and rehabilitation. Assistive technology · October 2010

DOI: 10.3109/17483107.2010.525290 · Source: PubMed

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REVIEW PAPER

Wheelchair propulsion biomechanics and wheelers’ quality of life:an exploratory review

JOHN W. CHOW1 & CHARLES E. LEVY2

1Methodist Rehabilitation Center, Jackson, MS 39110, USA and 2North Florida/South Georgia Veterans Health Service,

Gainesville, FL, USA

Accepted September 2010

AbstractPurpose. To provide an overview of associations between wheelchair propulsion biomechanics for both everyday and racingwheelchairs, wheeling-related upper limb injuries, and quality of life of manual wheelchair users through a synthesis of theavailable information.Methods. A search of publications was carried out in PubMed and SportsDiscus databases. Studies on wheelchairpropulsion biomechanics, upper limb injuries associated with wheelchair propulsion and quality of life of wheelchair userswere identified. Relevant articles cited in identified articles but not cited in PubMed or SportsDiscus were also included.Results. Wheelchair sports participation has positive impact on quality of life and research in racing wheelchairbiomechanics can indirectly promote the visibility of wheelchair sports. The impact of pushrim-activated power-assistedwheelchairs (a hybrid between manual and battery-powered wheelchairs) and geared manual wheels on wheelers’ everydaylife were discussed.Conclusions. The study of wheelchair propulsion biomechanics focuses on how a wheelchair user imparts power to thewheels to achieve mobility and the accumulated knowledge can help to improve wheelchair users’ mobility, reduce physicalstress associated with wheelchair propulsion, and as a result, enhance quality of life.

Keywords: Kinesiology, power-assist wheelchair, overuse injury, manual wheelchair

Introduction

Wheelchairs are primary mobility devices for indivi-

duals with locomotive disabilities for whom ambula-

tion is not possible or practical. More than half of

individuals with amyotrophic lateral sclerosis, cere-

bral palsy, multiple sclerosis, multiple system atro-

phy, progressive supranuclear palsy, and spinal cord

injury (SCI) rely on wheelchairs for mobility [1]. In

the USA alone, it is estimated that approximately 2.7

million people used a wheelchair for daily mobility in

2002 [2]. The number of wheelchair users in Europe

is estimated to be around 3.3 million [3]. A great

deal of research has been done related to different

aspects of wheelchairs. Using ‘wheelchair’ as the key

word, a search in PubMed in February of 2010

yielded over 4,000 articles. This paper will only focus

on a very narrow aspect of wheelchair use – the

propulsion biomechanics and its ties to the pain,

musculoskeletal injury, and quality of life.

Search strategy

The search of publications was carried out in

PubMed and SportsDiscus databases using combi-

nations of key words such as ‘wheelchair’, ‘propul-

sion’, ‘biomechanics’, ‘injury’, ‘pain’, and ‘quality of

life.’ Studies on wheelchair propulsion biomecha-

nics, biomechanics of wheelchair sports, upper limb

injuries associated with wheelchair propulsion, and

quality of life of wheelchair users were identified.

The only exclusion criterion was non-English litera-

ture. Screening of articles was completed collabora-

tively by both authors. Relevant articles cited in

identified articles but not cited in PubMed or

Correspondence: Dr. John W. Chow, Ph.D, Methodist Rehabilitation Center, Research, 1350 East Woodrow Wilson Drive, Jackson, MI 39110, USA.

E-mail: jchow@mmrcrehab.org

Disability and Rehabilitation: Assistive Technology, 2010; Early Online, 1–13

ISSN 1748-3107 print/ISSN 1748-3115 online ª 2010 Informa UK, Ltd.

DOI: 10.3109/17483107.2010.525290

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SportsDiscus were also included. About 300 articles

were identified in the initial search and about half of

them were included in this narrative review. Most

excluded articles reported outcome measures that

are not relevant to this review. We chose to limit the

data bases searched in this narrative review to those

that appeared to be most promising and relevant [4].

A more exhaustive search might be appropriate for a

systematic review.

Types of wheelchairs

There are a number of ways to classify wheelchairs.

For the purposes of this review, wheelchairs will be

classified as those designed for daily mobility versus

those designed with a specific sport in mind since

the types of biomechanical stressors are likely to be

different. For everyday use, persons with mobility

limitations may use manual wheelchairs, pushrim-

activated power-assisted wheelchairs (PAPAWs),

battery-powered wheelchairs, and scooters to meet

their mobility needs (Figure 1). Many of these

devices may have assistive technologies integrated

into the wheelchairs to facilitate mobility (see a

review by Sisto et al. [5]). Manual wheelchairs are

designed for those who have sufficient upper limb

strength and coordination to propel the chair they

occupy. Advances in material manufacture and

wheelchair design have led to lighter, smaller, and

more adjustable wheelchairs. Even with these ad-

vances, some potential wheelers require additional

assistance from mechanical gearing or battery power

sources when standard manual wheeling becomes

too painful or too exhausting.

Introduced in the late 1990s, PAPAWs are inter-

mediate alternatives between conventional power

and manual wheelchairs [6–8]. They require users

to stroke the pushrims to activate small, lightweight

motors, which then drive the wheels for a brief

period of time. To keep PAPAWs moving, users

must continue to stroke the pushrims as they would

to propel a standard manual chair.

Currently there are three power-assist systems

available in the USA – e�motion M15 manufactured

by Alber of Albstadt, Germany [9] and marketed by

Frank Mobility (Oakdale, Pennsylvania) in the USA,

the JW II, manufactured by Yamaha, Shizuoka,

Japan [10] and marketed as the Quickie Xtender by

Sunrise Medical (Longmont, Colorado) in the USA,

and the Tailwind manufactured by Next Mobility

(Canton, Michigan) [11]. In addition to the adjust-

ment for the sensitivity of the pushrim activation, the

e�motion system allows users to change the settings

for how much power is delivered after the handrim is

pushed, how quickly the motor responds after the

handrim is pushed, and how long the motor

continues to supply power after it has been triggered.

Once a setting is chosen, the same amount of power

assistance is delivered after each push regardless of

the amount of force applied to the pushrim [7]. The

JW II system regulates pushrim force with sets of

linear compression springs and records the force

with a potentiometer that senses the relative motion

between the pushrim and the hub. The potenti-

ometer signals from both wheels interface to a

microcontroller that coordinates control of each

wheel’s motor, which are attached to a transmission

within the hub [6]. The Tailwind uses a 2-input,

single output design where the first input is from the

pushrim and the second input is from a DC

brushless motor. The input from the pushrim is

in part directly transmitted to the wheel and in

part sends a torque signal to a motor that provides

Figure 1. The three basic types of everyday wheelchairs are manual (a), PAPAW (b), and electric-powered (c) wheelchairs.

2 J. W. Chow & C. E. Levy

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additional driving force to the wheel. The amount

of torque the motor provides and its rampup,

duration and decay are iteratively determined by a

software programme in the onboard microproces-

sors. The microprocessors interpret the torque signal

from the pushrim, monitor feedback from speed

sensors in the transmission and adjust motor output

appropriately [7].

The geared manual wheelchair is one of the

recently developed options available to manual

wheelchair users [12,13]. Available since 2004,

geared wheelchair wheels allow users to choose the

option of wheeling in a ‘lower gear’ so that climbing

inclines is less difficult [14]. Replacing standard

wheels with a pair of 2-geared wheelchair wheels

(MAGICWheels) add less than 10 lb (4.5 kg) of

weight and no additional width to the wheelchair.

Battery-powered wheelchairs (or simply power

wheelchairs), are typically controlled using a joystick

or switch arrays. They are used by those who are

unable to meet their functional needs in a manual

wheelchair. Even with sufficient arm strength and

coordination, some manual wheelchair users may

require geared wheelchairs, PAPAWs or power

wheelchairs to master certain situations or terrains.

Each type of daily mobility device has its advantages

and disadvantages. Optimal prescription and fitting

of wheelchairs are vital in meeting users’ personal

needs and interests and thus enhancing the quality of

life [15].

By definition, sports wheelchairs are optimised for

a specific narrow recreational activity. The most

common types of sports wheelchairs are racing

chairs for road or track and court chairs for wheel-

chair tennis, basketball or rugby. Sports wheelchairs

continue to evolve to meet the demands of peak

athletic performance. For example, racing wheel-

chairs used in the early 1980s resembled everyday

wheelchairs except that they featured lowered seat

heights and cambered rear wheels [16]. Today’s

racing wheelchairs have replaced the front castors

with a single wheel positioned at the end of a

horizontal post (Figure 2). Modern racing wheel-

chairs allow athletes to adopt a kneeling-forward lean

position to maximise stroke proficiency and mini-

mise the aerodynamic resistance. Sports ‘n Spokes

[17], a publication dedicated to sports and recreation

for wheelers, is an excellent resource for sports

wheelchairs.

Wheelchair propulsion biomechanics

Biomechanics is the study of the structure and

function of biological systems using the methods

of mechanics [18]. In the context of wheelchair

propulsion, wheelchair biomechanics involves the

study of how a wheelchair user imparts power to

the wheels to achieve mobility [19]. In general, the

primary goal of biomechanical analysis of wheelchair

propulsion is to generate knowledge that can be used

to improve performance and/or prevent injuries.

Either directly or indirectly, the knowledge accumu-

lated is likely to have implications to the quality of life

of wheelchair users.

Although measuring wheelchair propulsion in

natural environments (e.g., overground stroking using

subjects’ own chairs) is considered ideal [20–23],

most biomechanical studies of wheelchair propulsion

are conducted in laboratory settings using treadmills

[24–30], stationary wheelchair ergometers [31–39],

and dynamometer/roller systems [40–48] for ease of

data collection and standardisation across subjects.

However, laboratory testing may alter the factors of

balance and coordination as occurs under natural

everyday pushing activities. Furthermore, it may not

be appropriate to compare values collected from

different apparatuses because resistance character-

istics (that simulate overground stroking) experi-

enced by the subjects may not be identical. Despite

these limitations, findings from different studies

generally reveal similar trends in various aspects of

Figure 2. Modern racing wheelchairs allow athletes to adopt a tight kneeling-forward lean position to maximise stroke proficiency and

minimise the aerodynamic resistance.

Wheelchair biomechanics and user QOL 3

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wheelchair propulsion biomechanics. Most studies

report results in one or more of these three areas: (1)

kinematics – description of stroking motion, (2)

kinetics – upper limb joint loads, and (3) timing and

activation profiles of different muscle groups during

stroking.

Kinematics

For everyday manual wheelchair propulsion, the

stroking motion is a bilateral cyclic motion. For the

purpose of this review, a stroke cycle starts at the

instant the hand contacts the pushrim, and ends at

the instant immediately before the next hand contact

on the same wheel. The instant the hand loses

contact with the rim (hand release) divides a stroke

cycle into two phases – push and recovery phases

(Figure 3).

Stroke cycle parameters include average speed,

distance travelled, stroke time, stroke frequency,

push and recovery times and percentages, and

contact, recovery, and push angles (Figure 3).

Typical values of selected stroke cycle parameters

are presented in Table I. Other stroke cycle charac-

teristics commonly reported are ranges of motion of

the trunk and upper limb joints and segments

throughout the cycle and during different phases

[53]. Patterns of hand trajectory during a stroke cycle

are also of interest in different contexts [26,54,55].

Not surprisingly, wheeling and walking/running

share some common features in within-cycle char-

acteristics. For example, when expressed as a

percentage of the stroke time (cf. stride time in

walking), the relative push time (stance time)

decreases and the recovery time (swing time)

increases with increasing stroke speed (stride speed)

[29,30,38,45,56]. Increases in stroke frequency

(reciprocal of stroke time) and joint ranges of motion

are also associated with an increase in stroking speed

[25,45,56,57].

Kinetics

Because upper limb joint pain is prevalent amongst

wheelers [54,58–72] and likely to be related to the

repetitive stress of wheeling, evaluating the mechanical

load on these joints during wheelchair propulsion has

the potential to reveal the possible mechanisms of

injury, and thus suggest targets for intervention. The

locations, magnitudes, and directions of the force

and moment acting on the hand during the push

phase must be known before resultant (or net) joint

forces and moments can be determined using the

inverse dynamic approach. Contact forces and mo-

ments between the hand and pushrim are usually

measured using either a wheelchair ergometer/dynam-

ometer [33,36,37,44,73–77] or an instrumented

wheel [26,78–83]. A musculoskeletal model of the

upper extremity is needed for estimating glenohumeral

contact forces during wheelchair propulsion [84–86].

Low intensity wheelchair propulsion does not appear

to lead to high glenohumeral contact forces [86].

However, shoulder resultant joint forces and moments

increase considerably when pushing at faster speeds

[45,46,87], up an incline [46,81], or while fatigued

[88].

Muscle activation

Several studies have documented the muscle activa-

tion patterns during wheelchair propulsion using

surface [39,52,77,88–93] and indwelling [47,50]

electromyographic (EMG) techniques. In general,

anterior deltoid, biceps brachii, triceps brachii, flexor

carpi radialis, extensor carpi radialis, and pectoralis

major have been found to be active during the

push phase, while the middle and posterior deltoid

muscles are identified as the prime movers during

the recovery phase. Cerquiglini et al. [89] found the

latissimus dorsi to be most active during the final

phase of pushing, and the activity increased drasti-

cally when the resistance of the wheelchair ergometer

was increased to simulate a 2–3% incline. Using

indwelling EMG techniques to monitor different

shoulder muscles, Mulroy et al. [47] found the

anterior deltoid, sternal portion of pectoralis major,

supraspinatus, infraspinatus, serratus anterior, and

long head of biceps brachii to be active during

the push phase. The recovery phase muscles were

Figure 3. Critical instants and phases of a stroke cycle. The contact

and release angles indicate the locations of hand relative to the

wheel centre at the instants of hand contact and release,

respectively. The top dead centre is the highest point of the

wheel regardless of the wheelchair orientation.

4 J. W. Chow & C. E. Levy

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Wheelchair biomechanics and user QOL 5

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middle and posterior deltoid, subscapularis, supras-

pinatus, and middle trapezius. They did not observe

any consistent pattern of activity in the latissimus

dorsi. They concluded that the pectoralis major,

supraspinatus, and all recovery muscles were most

vulnerable for fatigue.

Inclines

Inclined surfaces are one of the most common

environmental barriers and a likely cause of shoulder

pain in wheelers [58,60,94]. Several studies have

examined the capabilities of wheelers while negotiat-

ing inclines [95–97]. Typically, the subjects were

asked to traverse inclines of different slopes and rate

the degree of easy/difficulty. Previous studies report-

ing upslope propulsion biomechanics used either

only one slope [81,98,99] or unnatural settings (i.e.,

treadmills and ergometers) [26,30,46,52,89,100]. In

a recent study, 10 young men with paraplegia were

asked to push on level and up a 7.3 m long ramp in

six slope angles (28–128 at 28 interval) at self-selected

normal and fast speeds [20] while kinematic and

surface EMG data were collected. One of the key

findings was that subjects started to alter their

kinematic and muscle activation patterns signifi-

cantly when the slope was increased to about 68.Major kinematic changes associated with increasing

slope include decreases in stroking speed and relative

recovery time and increases in stroke frequency, and

increased forward lean and angular velocity of the

trunk. As the slope increased, the subjects used the

strategy of compact stroking pattern (i.e., increased

forward lean, smaller push angle, higher stroke

frequency, and shortened recovery time). Muscles

controlling trunk motion are important because the

trunk becomes more active with increasing slope. It

is also worthy to note that those with higher levels

of paraplegia due to SCI are likely to have less

innervations to the trunk, and thus less access to

compensation techniques that rely on the trunk.

PAPAW

Different aspects of the PAPAW have been examined

in the past decade [6,7,50,53,101–110]. In terms of

propulsion biomechanics, the use of the PAPAW

significantly decreased upper extremity range of

motion when compared to manual wheelchair

stroking [53]. In addition to lower heart rate and

decreased perceived exertion, EMG activity for the

extensor carpi radialus, triceps brachii, anterior

deltoid, pectoralis major, infraspinatus, supraspina-

tus, and latissimus dorsi was significantly decreased

with the PAPAW [7,50]. This implies that the

PAPAW reduced the effort associated with wheeling

and has the potential to preserve wheelers’ upper

extremity joint function.

Geared manual wheels

Geared manual wheels (GMWs) are relatively new

and data on propulsion biomechanics are limited.

Using healthy subjects Howarth et al. [13] demon-

strated that peak EMG activity of selected shoulder

muscles reduced significantly during ramp ascent

with the use of GMWs. However, a significant

increase in integrated EMG (overall muscle effort)

due to a significant increase in ramp ascent duration

observed during the geared wheel condition may

indicate the potential for muscle fatigue if the gear

ratio is used for prolonged periods. Furthermore, the

increased wrist range of motion associated with

GMWs may promote development of repetitive

strain injuries at the wrist if the gear ratio is used

excessively.

Wheelchair racing

Wheelchair athletics (track and field) have drawn

particular attention from biomechanists [25,28,34,

39,41,42,91,111–127]. Modern racing wheelchair

design allows athletes to tuck their shanks under-

neath their thighs in a squatting posture (Figure 2).

In terms of supporting the body weight, the current

designs shift the main area of support from the

buttocks (sitting) to the shin areas (kneeling). As a

result, the athletes can adopt a near-horizontal trunk

position throughout a stroke cycle. Sanderson and

Sommer [28] suggested that an increase in forward

lean would promote the ability to transfer power

from the trunk to the pushrim. Because of the

forward leaning position and greater shoulder range

of motion, the recovery phase of the racing wheel-

chair stroke can be further divided into ascending

and descending recovery phases using the instant of

maximum elbow height [41,42].

Because of the changes in racing wheelchair design

and subsequent changes in body position and

stroking patterns, findings of studies conducted in

the 1970s–1980s and results collected using wheel-

chair ergometers or roller systems may not be

applicable to today’s racers. For example, Cooper

[115] reported that when the subjects were asked to

perform simulated sprints on a roller system, the

subjects reached 50% of their maximum sprint speed

after the first stroke. Over-ground sprinting data

collected on tracks clearly demonstrated that this is

not possible [114,123]. In spite of variations in

methodology, the involvement of biomechanics in

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wheelchair sport helps to optimise wheelchair design,

improve the mechanical efficiency of wheelchair

athletes, and minimise the risk of injury [128]. Such

assertion is certainly also applicable to everyday

chairs and their users.

Wheelchair propulsion related injuries

Wheelchair propulsion is very stressful to the

musculoskeletal structures of the upper limb [129].

As a result, manual wheelchair users may develop

overuse injuries primarily in the shoulder [58–60,

62,65–69,71,130–138] and wrist [54,61,64,67,70,

72,130,134,137,139] areas (Table II). Although less

frequent, pain at the elbow and neck is also common

amongst wheelers [67,71,130,134,137,140]. In a

survey conducted at a National Veterans Wheelchair

Games, 60% of the responders reported neck and

upper back pain during the past month [140]. Upper

limb pain is also widespread in wheelchair athletes

[135,141–143]. It has been suggested that the risk of

joint and nerve pain could be reduced by altering

stroking mechanics such as taking long smooth

strokes when propelling a wheelchair [144–146] or

using alternative equipment [12].

Despite the fact that wheelchair athletes are subject

to more load and repetitive stress through their

participation in sporting activities in addition to

the physical stress of daily life, the odds of having

shoulder pain were lower among athletes when

compared to nonathletes [63] (Table II). It has been

suggested that athletic activity has a protective effect

on the shoulder, with wheelchair athletes having less

pain overall and more pain-free years. However, it is

not certain whether nonathletes have more pain

because they are not athletic or they are not involved

in athletic activities because they have shoulder pain.

It is also possible that wheelchair athletes are more fit

and less likely to report pain than those who chose

not to engage in sports. Participation in sports

activities may confer an additional health benefit:

Sports active wheelers may realise an increase bone

mineral density in their weight-bearing upper limbs

which may help protect against osteoporosis [147].

Quality of life of wheelchair users

There is no single, clear, universally accepted

definition that exists for the term quality of life

(QoL). It generally refers to the set of factors

Table II. Prevalence of upper extremity joint pain (%) in wheelchair users reported in the literature in chronological order.

Reference Number of Subjects Diagnosis Shoulder pain Elbow pain Wrist pain

Yang et al. [72] 166 Paraplegia 7 7 60*

Alm et al. [58] 88 SCI 40 7 7Brose et al. [59] 49 SCI (athletes) 25 7 7McCasland et al. [66] 63 Traumatic SCI 70 7 7Salisbury et al. [68] 27 Tetraplegia 70 7 7van Drongelen et al. [71] 169 SCI 39 13 15

Finley and Rodgers [135] 52 Mostly SCI 29 7 7Samuelsson et al. [69] 56 SCI 38 7 7Fullerton et al. [63] 172 Mostly SCI (athletes) 39 7 7

85 Mostly SCI (nonathletes) 66 7 7Boninger et al. [133] 28 Paraplegia 32 7 7Ballinger et al. [131] 89 SCI 30 7 7Curtis et al. [60] 195 Mixed 50 7 7Dalyan et al. [134] 130 SCI 42 21 31

Lal [65] 53 SCI 11 7 7Schroer et al. [139] 162 Paraplegia 7 7 43{

Pentland and Twomey [67] 52 SCI 39 31 40

Sie et al. [137] 239 SCI 42 15 10

Davidoff et al. [61] 31 Paraplegia 7 7 55{

Silfverskiold and Waters [138] 60 SCI 35 7 7Gellman et al. [64] 77 paraplegia 7 7 49*

Tun and Upton [70] 60 paraplegia 7 7 50

Bayley et al. [132] 94 paraplegia 31 7 7Aljure et al. [130] 47 paraplegia 40 40x 7Nichols et al. [136] 563 SCI 51 7 7

*Carpal tunnel syndrome.{Wrist and/or hand pain.{Median mononeuropathy.xUlnar neuropathy.

Wheelchair biomechanics and user QOL 7

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composing personal satisfaction with life and it is

recognised to consist of health-related and non-

health-related aspects of living [148]. Among in-

dividuals of different levels of functional status and

disability, wheelchair-dependant persons tend to

have lower perceived QoL than those who are

independently mobile [149,150]. Furlong and Con-

nor [151] identified four main factors of disability-

related stress – access, physical stress, social stress,

and burden of care – that are closely related to QoL

of wheelchair users, with access being the most

influential factor. Although wheelchairs enable mo-

bility and independence, environmental barriers

often restrict wheelers from participation in diverse

activities outside the home [152–154]. Relative to

physical stress, persons with SCI who reported lower

subjective QoL and physical activity scores experi-

enced significantly higher levels of shoulder pain

[155]. There were studies reporting impacts of

neuropathic or bodily pain on QoL in SCI [156–

160]. However, whether the subjects were manual

wheelchair users or the pain was wheelchair propul-

sion related could not be discerned in these reports.

As pointed out by Giacobbi et al. [161], previous

investigations on the possible benefits of physical

activity in people with disabilities tended to focus

on physical benefits [162] while neglecting to

investigate the social and psychological conse-

quences. Using a combination of quantitative (ques-

tionnaires) and qualitative (in-depth interviews)

approaches, Giacobbi et al. [161] examined links

between physical activity and QoL experienced by

individuals with physical disabilities recruited from a

wheelchair users’ basketball tournament (12 men, 14

women). Their analyses revealed that their partici-

pants perceived a number of psychological, social,

and health benefits associated with involvement

with physical activity. The subjects’ evaluations and

descriptions of their physical activity experiences

appeared to support self-efficacy beliefs, feelings of

empowerment, and motivation for continued invol-

vement. In a recent survey of 132 US veterans with

disabilities participated in the National Veterans

Wheelchair Games (NVWG) and the Winter Sports

Clinic (WSC), the majority of them stated that the

NVWG/WSC improved their life [163]. Other data

from the survey suggested that participation in

events such as the NVWG and WSC could provide

psychosocial benefits to veterans with disabilities.

Inconsistent findings have been reported relative

to the impact of PAPAW on users’ daily life. When

manual wheelchair users with paraplegia [104] and

tetraplegia [103,104] were provided with a Yamaha

JWII and instructed to use either their own manual

wheelchair or PAPAW for mobility according to

their preference in the home environment and

community for two weeks, the PAPAW did not

result in significantly greater community participa-

tion, satisfaction, and psychosocial impacts when

compared to the two weeks prior to PAPAW use.

Based on qualitative interviews conducted on 20

manual wheelchair users before, during, and after

8-week use of the e�motion system, Giacobbi et al.

[105] revealed that most wheelers perceived positive

experiences with the power-assist wheels, including

access to new and different activities. Despite diffi-

culties with transport in and out of a vehicle and

battery life, most participants felt that PAPAW

provided more independence and social opportu-

nities.

Using an ABA design, Levy et al. [164] showed

that use of power-assist wheels was associated with

significantly further travel. Because PAPAWs allow

users to wheel with less effort and stress, they are

likely to be preferred over power chairs by wheelers

who see self propulsion as an expression of autonomy

and independence. Although more cumbersome

than manual chairs [typically 30–45 lb (14–20 kg)

heavier than a lightweight manual chair], PAPAWs

are significantly lighter than comparable power

chairs, and thus are generally easier to transport.

Consequently, PAPAWs may provide manual wheel-

chair users with a less physiologically stressful means

of mobility with fewer adaptations to the vehicle or

home environment [6,106]. In addition to manual

wheelchair users, the PAPAW may provide an alter-

native to the power wheelchair for some individuals

requiring power mobility [165].

Unlike PAPAWs, GMWs are relatively new and

limited investigations have been conducted to

examine the impact of GMW on users’ function

and quality of life. To investigate the impact of

GMWs on shoulder pain and function in manual

wheelchair users, Finley and Rodgers [12] followed a

group of wheelchair users with shoulder pain who

used the MAGICWheels for 5 months. They found a

significant reduction in should pain after the inter-

vention but there was no difference in Wheelchair

Users Functional Assessment (WUFA).

Connections between wheelchair propulsion

biomechanics and QoL

The study of wheelchair propulsion biomechanics

can contribute directly and indirectly to wheelers’

QoL (Figure 4). Although the exact causes of upper

extremity pain in wheelchair users are not known,

wheelchair propulsion is likely to be one of the risk

factors [54,85,87,144,166]. If the nature of the

mechanical load can be identified through biome-

chanical analyses, specific exercise programs and/or

design changes can be better tuned to prevent

overuse injuries [82,167]. While kinetic analyses of

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upper extremity joints provide some indication of

the mechanical loads at different joints, EMG and

kinematic analyses provide further insights into

muscle function and propulsion techniques that

may help to minimise the demand placed on the

upper extremities of wheelchair users. Biomechanical

analyses of propulsion for different wheelchair

designs can reveal advantages and disadvantages

relative to the physical demand associated with each

design.

Through publications in scientific journals and

magazines, wheelchair sport scientists help to raise

the visibility of wheelchair sports and perhaps

indirectly promote physical activities among wheel-

chair users. For individuals with disabilities, sports

and recreational activities can facilitate community

reintegration [168], as well as health [162] and

social/psychological [161,163,169,170] benefits.

In summary, biomechanical analysis of wheelchair

propulsion generates knowledge that can be used to

improve stroking mechanics and prevent upper

extremity injuries. The accumulated knowledge can

help to improve wheelchair users’ mobility, reduce

physical stress associated with wheelchair propul-

sion, and as a result, enhance quality of life. It is

anticipated that the role of biomechanics would

become more prominent when research findings are

applied to the objective evaluation of wheelchair

propulsion in clinical practices [171].

Acknowledgement

The preparation of this review was supported in part

by the Wilson Research Foundation (Jackson, Mis-

sissippi, USA).

Figure 4. Possible contributions of wheelchair propulsion

biomechanics to the quality of life of manual wheelchair users.

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