Wheelchairs have been designed as an assistive device for those who have lost function in their legs or have difficulties in walking; they allow such people to mobilise on their own, and provide the user with a higher level of independence. Whilst the wheelchair is a useful device that can significantly improve one’s quality of life, it relies heavily on the arms and shoulders of the user. Therefore it is essential to understand the importance of maintaining upper body function and strength.
The human body has not evolved to rely upon the upper body for its primary source of ambulation. Those who use a wheelchair to mobilise have an increased demand of stress on the shoulder complex and are at a higher risk of developing chronic shoulder conditions because of overuse injuries.
The typical movement of the upper body when propelling a wheelchair forwards places increased stress on the shoulder through a downwards force as the movement encourages shoulder protraction, shoulder elevation and flexion through the thoracic spine. Common pathologies associated with shoulder pain in wheelchair uses are rotator cuff tears, shoulder impingement, bursitis, tendinopathy and glenohumeral instability. It is not only important to maintain function and strength to prevent the development of chronic conditions, but also to assist in everyday tasks and ease of wheelchair use; particularly for those who have lost the function of their legs and their ability to perform everyday tasks rely on their upper body.
When preserving the function and strength of the shoulder complex, there are three components that should be included in an exercise intervention.
- Stretching / Releasing
As the mechanics of propelling a wheelchair can elicit adaptive behaviours at the shoulder joint and promote poor posture, muscular imbalances can emerge causing tightness due to prolonged shortening of the muscle fibres. Due to the increased stiffness of the musculature, mobility of the shoulder can become impacted, and movement is restricted. Through stretching / releasing, tightness in the muscle fibres can be reduced, mobility can be regained and unnecessary strain on the shoulder joint can be reduced. Below are some examples of stretches and releases that can be implemented.
- Shoulder Setting
Once mobility is regained within the shoulder joint, it is essential to focus on posture through shoulder setting. The muscles of the shoulder joint have equal and opposite opposing forces. Therefore when one opposing force becomes stiff and tight the other becomes overstretched and weak. Most commonly wheelchair users who have adapted shoulder elevation and protraction movement patterns when propelling will present with reduced strength and ability to perform shoulder retraction. The importance of improving shoulder setting through shoulder retraction is so that the shoulder joint can maintain a neutral position, reducing the risk of muscular imbalances occurring, which places uneven forces through the shoulder joint. Here are just some examples of shoulder/scapular setting exercises.
- Muscular Strength
Lastly one of the most obvious components to include in a prehabilitation program is strength. Through increased strength of the musculature around the shoulder joint and muscles involved in arm movements to assist in wheelchair propulsion, shoulder stability and muscular endurance can be improved and maintained. This is crucial as ambulation in a wheelchair requires consistent and repetitive motions to keep the chair moving. In addition, those who have lost function of their legs may still perform transfers to and from their chair independently, requiring strength and endurance in their arms and stability in the shoulder joints to be able to shift their body weight. Here are some examples of strength-based exercises for shoulder stability and strength.
Whilst these principles and exercises are designed to maintain shoulder health and function, it is important to note that every person’s treatment is different and not one exercise program will be suitable for all. Before starting an exerise regime it is important to consult your Exercise Physiologist to discuss your abilities and determine what intervention would be most suitable for your circumstances.
