An Investigation of Musculoskeletal (MSK) Upper Limb Injuries Sustained from Manual Wheelchair Use

: Implications of Pain and the Medical and Rehabilitative Approaches to Treatment

Abstract

Upper limb pain in manual wheelchair users negatively affects participation in social and recreational activities, completion of Activities of Daily Living (ADLs), sleep and vocational activities. Treatment of upper limb pain in manual wheelchair users can often prove difficult; as with any injury relative rest is required in order for the upper limb to recover. As the upper limb is required for mobility on a daily basis, often this is not feasible. The overall aim of this thesis was to explore the impact of upper limb injuries sustained by Spinal Cord Injured (SCI) manual wheelchair users, the medical and rehabilitative approach to treatment, the perspectives of SCI patients as to how upper limb pain affects daily life and the perspectives of clinicians involved in the treatment of these injuries. In addition, a wheelchair skills training project was piloted with young manual wheelchairs to assess the feasibility of delivering skills training in a community setting.

In study 1 (Chapter 2), a systematic review following the Preferred Reporting Items of Systematic Reviews and Meta-Analysis (PRISMA) guidelines was conducted to examine the prevalence of upper limb injuries in the SCI population. Prevalence rates of upper limb pain varied widely, with the shoulder the most common site of pain investigated. Pain was significantly associated with length of time since injury but not age. Pain was exacerbated primarily by outdoor wheeling, pushing up ramps and inclines and wheelchair transfers. Little information was available regarding treatments prescribed, however in those studies that did report treatment interventions, medication was primarily used to manage pain. Treatment recommendations included education of participants on joint protection and energy conservation to preserve the upper limb, and education on correct wheelchair techniques to avoid abnormal movements which contribute to the development of upper limb pain. Recommendations from the review stated that further research is required to establish the causation of injuries and the functional limitations of pain.

In study 2 (Chapters 3 and 4), a mixed methods study was undertaken to establish the prevalence of upper limb injuries in the SCI population of Northern Ireland, the treatments availed of by this cohort and the perspectives of SCI participants in relation to the impact pain has on their daily lives, and the perception of healthcare professionals involved in their care. Shoulder pain was again the most prevalent site of pain reported, followed by neck, xvi back, elbow, hand and finger pain. Prevalence of pain was poorly reported in the medical notes, with little to no information regarding any treatments availed of by participants documented. During one-to-one interviews, participants reported that pain affected them in all aspects of daily life and this was reflected in that 24/32 domains of the “ICF core set for SCI: chronic setting” were referenced during interviews. In relation to treatment, participants primarily reported self-managing their pain. Participants reported a lack of specialised services to provide them with advice on managing their pain. Participants reported good benefits from attending allied health services such as physiotherapy and occupational therapy, unfortunately they reported only short term relief from treatments availed of overall. The majority of participants had a particularly negative view of the Regional SCI (RSCI) centre. Many had not been called for review in over ten years, and one participant’s medical notes were unable to be located.

Only three healthcare professionals were agreeable to interview (3 occupational therapists). Their sentiments echoed that of the SC participants in that there are no specialised SCI services in the community. Participants reported a distinct sense of responsibility in treating their patients as they are consciously aware that once they leave the RSCI they may never receive the same level of specialised treatment in the community. Participants felt that upper limb pain was not a priority for patients on leaving the RSCI. Upper limb pain was more prevalent in the tetraplegic population where their upper limb pain was attributed to their level of injury, not an overuse injury as is investigated in this study. Wheelchair skills training was identified as a key element of rehabilitation. Participants identified this as crucial to a patient’s recovery, in that if they could not propel their chair, they could not attend therapy, therefore slowing down their recovery.

The concept of wheelchair skills training was highlighted in both chapters 1 and 3 as being key to both SCI patient’s recovery and their ability to be independent. Following this a systematic review following PRISMA guidelines of wheelchair skills test was undertaken to identify the most reliable and valid tool to measure wheelchair skill ability in manual wheelchair users (Chapter 5). The review highlighted ten different skill tests, each measuring various aspects of wheelchair use. The most comprehensive skills tests included a battery of skills focused on propulsion, ramps, sprints and transfers while also incorporating xvii practical tasks such as picking an item off the ground, crossing a road and propelling a wheelchair while carrying an item in one hand. The majority of tests had been tested with a variety of conditions and diagnoses and were therefore suitable for use with a wide population of manual wheelchair users.

In Chapter 6, a wheelchair skills training programme was designed by the Regional Wheelchair Skills training therapist and was implemented as an assessment graded for use with children, to assess skill level pre and post an eight month skills training programme. All participants showed a significant increase in the intermediate and advanced levels of the skills assessment. Participant feedback was mainly positive via the impact questionnaire and participants reported improvement in their confidence and independence. Overall, the programme was feasible to deliver and enabled participants to mobilise independently while increasing their confidence as a wheelchair user. This programme is also currently being rolled out across Northern Ireland with a number of occupational therapists now trained in the delivery of wheelchair skills training.

In conclusion, this thesis contributes knowledge to an evidence based approach of identifying factors relating to upper limb pain in manual wheelchair use. It established that upper limb pain is prevalent, however with the small sample size utilised in all studies, results should be interpreted with caution. It obtained information regarding the treatment pathway for the treatment of upper limb injuries, the functional impact pain has on daily life for SCI manual wheelchair users, and the clinical perspectives of what can be done to ensure patients are better supported in the community. In addition, it examined the efficacy of delivering wheelchair skills training in the community, and found participants not only showed an improvement in skill level, but they also felt more confident and independent as a wheelchair user going forward.

Date of Award	Feb 2019
Original language	English
Sponsors	DEL
Supervisor	Daniel Kerr (Supervisor) & Mary Hannon-Fletcher (Supervisor)