856
Pushrim Forces and Joint Kinetics During Wheelchair
Propulsion
Rick N. Robertson, PhD, Michael L. Boninger, AID, Rory A. Cooper, Phi), Sean D. Shimada, MS
ABSTRACT. Robertson RN, Boninger ML, Cooper RA,
Shimada SD. Pushrim forces and joint kinetics during wheel-
chair propulsion. Arch Phys Med Rehabil 1996;77:856-64.
Objective: To investigate pushrim forces and joint kinetics
during wheelchair propulsion and to discuss the differences
between inexperienced and experienced wheelchair users.
Design: Cohort study.
Setting: Human engineering laboratory at a state university.
Subjects: Four men who use manual wheelchairs for mobility
and four nondisabled men who did not have extensive experi-
ence pushing a wheelchair; all subjects were asymptomatic for
upper extremity pain or injury.
Methods: Subjects pushed a commonly used wheelchair fit-
ted with a force-sensing pushrim on a stationary wheelchair
dynamometer. Video and force data were collected for 5 strokes
at one speed of propulsion. Pushrim forces and net joint forces
and moments were analyzed.
Main Outcome Measures: Pushrim forces, radial (Fr) and
tangential (Ft), were analyzed and compared for both groups in
relation to peak values and time to peak values and as ratios of
overall forces generated. Net joint forces and moments were
analyzed in a similar fashion.
Results: Pushrim forces and joint moments were similar to
those previously reported, with radial forces averaging between
34 and 39N and tangential forces ranging on average between
66 and 95N. Tangential forces were higher than radial forces,
and mean ratios of tangential forces to the resultant force were
approximately 75%, whereas mean radial force ratios were ap-
proximately 22%. All subjects showed higher joint moments at
the shoulder than at the elbow or wrist. A large component of
vertical reaction force was seen at the shoulder. Significant
differences (p < .05) were found between groups for peak
tangential force and time to peak tangential and peak vertical
forces, with wheelchair users having lower values and longer
times to reach the peak values.
Conclusions: Discrete variables from the force-time curves
can be used to distinguish between wheelchair users and nonus-
ers. The experienced users tended to push longer, used forces
with lower peaks, and took longer time to reach peak values.
This propulsive pattern may have been developed to reduce the
From the Human Engineering Research Laboratories, Division of Physical
Medicineand Rehabilitation,Departmentof OrthopaedicSurgery,and the Depart-
ment of RehabilitationScienceand Technology,Schoolof Health and Rehabilita-
tion Sciences,Universityof Pittsburgh.
Submitted for publication October 10, 1995. Acceptedin revisedform Decem-
ber 19, 1995.
Supported in part by The UnitedStates Department of Veterans Affairs, Reha-
bilitation Research and DevelopmentService(B686-RA), and The United States
Department of Education, RehabilitationServicesAdministration(H129E00005).
No commercial party having a direct financial interest in the results of the
research supporting this article has or will confer a benefit upon the authors or
upon any organization with which the authors are associated.
Reprint requests to Michael L. Boninger,MD, Divisionof Physical Medicine
and Rehabilitation,Suite901 KaufmannBuilding,3471 FifthAvenue,Pittsburgh,
PA 15213.
© 1996by the AmericanCongressof RehabilitationMedicineand the American
Academy of Physical Medicineand Rehabilitation
0003-9993/96/7709-372453.00/0
Arch Phys Med Rehabil Vo! 77, September 1996
chance of injury by minimizing the forces at the joints, as a
means of maximizing efficiency or as a combination of these
factors. More work investigating 3-dimensional forces and the
influence of seating position and various conditions of propul-
sion such as speed changes, ramps, and directional changes on
injury mechanisms needs to be completed.
© 1996 by the American Congress of Rehabilitation Medicine
and the American Academy of Physical Medicine and Rehabili-
tation
EPETITIVE STRAIN INJURY is remarkably common in
R individuals who use manual wheelchairs. The prevalence
of shoulder pain in individuals with spinal cord injury (SCI) is
between 31% and 73%. ~-5 Other studies show that the preva-
lence of carpal tunnel syndrome in this group is between 49%
and 73%. 6"9 In these studies the authors suggest that the repeti-
tive trauma to upper extremity joint structures while propelling
a wheelchair is, in part, responsible for these injuries. Because
the upper extremity is so important for activities of daily living,
pain in this area can be a serious problem leading to lost inde-
pendence, increased cost of care, and additional secondary inju-
ries.
Little information is available concerning the forces applied
to the pushrim or the forces developed across the joints during
wheelchair propulsion due to the complexities of developing a
reliable system for measuring pushrim forces. Measurement of
forces applied to the pushrim has been accomplished by static
force measurements, ~°'~ by external devices such as force
plates~2 and connections to isokinetic dynamometers,~3'~4 and by
direct measurement of pushrim forces through various kinds
of force measuring transducers. 15-22 Few of these studies have
directly measured pushrim forces while individuals pushed
commonly used wheelchairs.
Veeger and coworkers ~5'J8'23 provided some information on
pushrim forces with a wheelchair simulator that measured
torque at the hub and forces applied to the pushrim through 3-
dimensional force transducers mounted to support structures.
They showed that increasing the speed of propulsion did not
increase all components of the pushrim forces and that generally
the vertical forces were larger than those in the horizontal direc-
tion.
Joint forces have been studied by few authors. Larger joint
moments have been noted with increases in external power
output, with the highest moments occurring at the shoulder
during flexion and adduction and the anterior deltoids and pecto-
falls major acting as primary movers. 24It was shown that fatigue
did not affect the magnitude of joint moments or joint reaction
forces and that joint moments and joint power were highest
during shoulder joint flexion. 17 Joint moments at the shoulder
were found to be much higher than at the wrist or the elbow,
when subjects pushed a wheelchair on a treadmill. Higher speed
and greater slope resulted in greater loads on the 3 joints, with
the effect of slope being more significant than that of speed. 25
Although these studies report important findings related to
the kinetics of wheelchair propulsion, a comprehensive assess-
ment of pushrim forces and joint forces has not been reported.
 WHEELCHAIR PROPULSION KINETICS, Robertson 857

Additionally, the reported results are limited because subjects

either pushed in simulated wheelchair systems or were not Y
wheelchair users. Understanding how forces are generated by
the individual and applied to the pushrim will provide insight
into how these forces are related to optimizing efficiency, im-
pusim )
proving performance, and identifying the mechanisms of inju- Fx
ries such as carpal tunnel syndrome, elbow tendonitis, and rota-
tor cuff injuries, with the goal of developing injury prevention
.F t
techniques.
The purposes of this article are to present a detailed analysis
of pushrim forces and joint moments while subjects pushed a
commonly used wheelchair, to show the effect of individuals
experienced in using a wheelchair on these forces, and to discuss [] Point of force application
the findings as they relate to upper extremity injury. This is one
of the first articles to describe pushrim forces and joint kinetics Fig 1. The forces and moment used to analyze the propulsive stroke. Fx,
while subjects pushed in a commonly used wheelchair. This horizontal; Fv, vertical; and Mz (moment about the hub) were determined
paper presents unique descriptions of pushrim forces, particu- from the SMART w~l. F~, radial and Ft, tangential were determined by a
method described in the text, The angle ~ defines the point of force
larly related to the tangential and radial components. Critical application (PFA).
variables derived from these force-time curves are used to dis-
tinguish differences between experienced and nonexperienced
wheelchair users. Additionally, the relationship of these vari- the forces (Fx--horizontal, Fy--vertical) and moment (Mz---
ables to upper extremity injury mechanisms is explored. moment about the hub) in the global reference frame. The kl
to k3 represent the calibration constants, R the pushrim radius,
METHODS V~ to V3 the recorded voltages from the strain gages, and 0
represents the angle of beam A referenced to top dead zero as
Subjects 0 °. Zero camber is assumed.
Each of 8 subjects (4 men who were wheelchair users and 4
men who were not wheelchair users) gave informed consent to
participate in this study. A profile of each subject is given in Fx=V~kjcosO+ V2k2cos(O+~)+ V3k3cos (0 + ~)
table 1. Subjects were asymptomatic for upper extremity pain
or injury as determined by questions addressing their medical
history, and no subject reported upper extremity involvement Fy = V~k~sin O + V2kesin (O + ~ ) + V3k3sin (O + ~ )
related to their disability.

Anthropometry Mz = VikIR + V2k2R+ V.~k3R

All body segment parameters were calculated for each sub-
ject. The segmental properties calculated for the hand, forearm, Based on a determination of the forces and moment, the
and arm included the moment of inertia and location of mass tangential (Ft) and radial forces (Fr) were determined from
centers. To make these determinations, segment proportional equations 1 and 2, below, and are illustrated in figure 1.
weights and lengths were required. The segment masses were
calculated using anthropometric constants that give segment Ft=Mz'R ~ (1)
mass as a fraction of total body mass. Data were determined F 2=F2, + F ~ = F r 2 + F 2 (2)
from Winter, 26 adapted from Dempster. 27 Segment lengths were
measured and the radius of gyration of each segment with re- If the individual applies a moment to the pushrim, then the
spect to the proximal end was calculated. moment at the hub is the sum of the hand moment and the
tangential component transmitted from the hand to the pushrim
Force-Sensing Pushrim (SMART wheel) (equation 3, below). Veeger and colleagues23 described a tech-
Engineering details of the force measuring wheel nique for making this determination from their wheelchair dyna-
(SMART wheel)have been outlined previously. 16In brief, 3 beams mometer and this equation was used in the model used in this
instrumented with strain gages connect the pushrim to the hub. paper to calculate net joint moments,
The following equations describe the method used to calculate
Mhub = Mzhand + F t ' R J (3)
Table 1: Subject Information
Point of Force Application
Age Height Weight
Subject (yr) (m) (kg) Nature of Disability The point of force application (PFA) describes a unique loca-
Non-wheelchair users tion on the pushrim where the resultant force is seen to be
1 25 1.77 81.5 None applied. In previous studies, the PFA was assumed to be coinci-
2 23 1,77 76.9 None dent with either the 2nd or 3rd metacarpophalangeal (MP) joint.
3 28 1.77 77.8 None As described in the following section, the PFA can be deter-
4 28 1.77 76.9 None
Wheelchair users mined solely from pushrim force and moment data.
5 34 1.87 72.4 Left leg amputee The forces Fx and Fy in the world coordinate frame are the
6 33 1.85 74.7 T-10 SCI components along the x and y axis, respectively, of the resultant
7 42 1.75 65.6 Postpolio F. Similarly, Fr and F~ in the wheel reference frame are compo-
8 30 1.68 90.1 T-4 SCI
nents of F as well. The wheel coordinate frame can be viewed

Arch Phys Med Rehabil Vol 77, September 1996

858 WHEELCHAIR PROPULSION KINETICS, Robertson
as a rotated version of the world coordinate frame. This informa-
tion can be used to determine the PFA. The resultant F is a
function of Fx and Fy or F, and Ft as shown in equation 2.
The angle F makes with respect to Fx is governed by the
relationships
Fx
cos 01 = - -
F
F,
sin 01 = m
F
and the angle F makes with respect to F~ is governed by a
similar~set of equations
cos 02 = --F"
F
F,
sin 02 = --
F Testing Protocol
Unit basis vectors for the xy and rt coordinate systems can be
defined from 0j and 02, respectively.
f~, = cos 0,[,+ sin 0~1
Fr, = cos 02~2 + sin 0z~2
The angle between the xy and rt coordinate systems completely
specifies the PFA location.
,f in0 ]
~ a@" 02
COS O,-2 = ~ ' * ,-~ = [COSOl sin OIl_COS
• an analog tachometer mounted at the front of the dynamometer.
: L- J
The PFA angle is then determined by taking the arc-cosine of
equation 7 and using information based on the normal stroke
pattern to determine in which quadrant the hand is located. This
last step must be done because there are two solutions to equa-
tion 7, which are 180 ° transposed.
The PFA may be relatively unstable at the beginning and end
of the stroke, when forces are low. To minimize this effect, the
PFA was constrained to maintain a fixed relationship with a
known point on the rotating wheel. The SMART whee~ has an
optical encoder that keeps track of its angular rotation. This
device outputs digital pulses that represent 0 ° to 360 ° rotation
of the wheel. The system is designed such that when one of the
beams (denoted beam A) reaches top dead center, the optical
encoder outputs 0 °. Determining the angle difference between
this beam and the PFA, in the middle part of the stroke where
the PFA is more stable, allows us to transform the PFA location
at the beginning and end of the stroke to maintain this angular
difference, in effect increasing the signal-to-noise ratio.
Calculation of Joint M o m e n t s
Our laboratory has previously described the method used to
determine the net joint forces and moments. 28'29Briefly, a gen-
erai link-segment model using an inverse solution with Newton-
Euler method based on a variable degree of freedom body coor-
dinate system (ie, the number of body segments is not fixed)
was used. A recursive matrix back propagation algorithm was
derived to improve computational efficiency.
Arch Phys Med Rehabil Vol 77, September 1996
ro = fifo + Ifi + ~Itv + 1VIg (8)
where ~p = reaction force and moment vector at the proximal
end, • = moment arms from proximal to distal end, [2 and w
= angular velocity matrices, ?D = reaction force and moment
vector at distal end, I = segment mass and moments of inertia
about the mass center, fi = linear and angular accelerations at
mass center, 1VI = force and moment contribution at distal end
from center of segment mass, and g = gravitational acceleration.
A pseudo-code real-time implementation of equation 8 is
(4)
for j = 1,n
f'p(j, t) = ~p(j, t)fD(j, t) + I(j, t)~(j, t) + ~2(j, t)I(j, t)w(j, t)
+ 1VI(j, t)g fD(j + 1,t) = -fo(J, t)
end
(5)
Before testing each subject, highly reflective markers were
attached to the shoulder (acromion process), elbow (lateral epi-
condyle), wrist (dorsal surface half way between styloid pro-
cesses) and 3rd metacarpophalangeal joint. Each subject was
(6) seated in a Quickie 1 wheelchair a fitted with the a force sensing
SMARTWh~e~~6 on the right side, with the chair secured to the
wheelchair dynamometer. 3°'3~ Subjects practiced pushing on the
dynamometer until they were comfortable with the set-up. Sub-
jects were asked to push the wheelchair between 1.5 and 2.0mph
(.67 and .89m/see). Subjects monitored their speed by viewing
Signals from the force-sensing pushrim were collected at 75Hz
per channel while a single video camera recorded sagittal mo-
tion data at 60Hz. Data were collected for approximately 30
seconds, and 5 consecutive strokes in the middle of the bout
were used for analysis. Processing of the signals from the beam-
mounted strain gages resulted in a determination of forces in
the x and y direction and moment about the z-axis (x--anterior-
posterior; y--superior-inferior; z--medial-lateral). A cubic
spline function was used to interpolate the force data to 60Hz.
Kinematics. Joint angles and linear and angular accelera-
tions of joint segments were determined from the video data
utilizing Peak5 data analysis software, b
Statistics
A repeated-measures analysis of variance (ANOVA) with a
probability level set at p = .05 was used to determine if differ-
ences existed in critical events on the pushrim force curves
and joint moment curves between groups (wheelchair users and
nonusers). A one-way ANOVA was used to determine if sub-
jects within a group exhibited significant differences for these
variables. The large volume of data required to be collected and
analyzed for each subject precluded the use of a large number
of subjects for this study. Determination of statistical power
was difficult because this type of data has not been previously
collected with a comparable setup, and expected variation in
the data was unknown. To enhance statistical power, a repeated-
measures analysis was used to investigate significant main effect
differences.
RESULTS
P u s h r i m Forces
Table 2 lists the means and standard deviations for selected
critical variables for both groups and summarizes the results
 WHEELCHAIR PROPULSION KINETICS, Robertson 859

Table 2: Means and Standard Deviations of Critical Variables Derived 90I

From the Force-Time Curves
Non-
Wheelchair Wheelchair Significance 80
Parameters Users Users (p)
,,/'/" ~.
Peak hub moment (Nm) 22.6 (8.7) 25.2 (3.6) .238
70
Peak Ft (N) 94.6 (10.1) 66.2 (14.4) .0001" 60
Time to peak Ft (sec) .32 (.07) .40 (.08) .0015"
Peak Fr (N)
Time to peak Fr (sec)
34.2
.18
(18.6)
(.07)
39.2
.15
(11.1)
(.05)
.309
.127
7 50
~-~ //
Peak Ft at impact spike ~ 40
(N) 49.0 (17.5) 4t.8 (19.8) .226 ~-
Peak Fr at impact spike [.~ 30
(N) 28.5 (13.7) 38.2 (11.9) .022*
Time to Peak Impact 2(3
Spike from Fy curve ,l
(sec) .134 (.066) .137 (.030) .406 1C
Mean ratio Fr (Fr2/F2) .209 (.125) .222 (.088) .872
Maximum ratio Fr (FrZ/F2) .700 (.200) .700 (.144) 1.0 0
Mean ratio Ft (Ft~/F~) .791 (.125) .728 (.085) .439 -1( i i r
Maximum ratio Ft (Ft=/F~) .999 (.001) .952 (.096) .358 0 0.1 0.2 0.3 0.4 0.5 0.6 0'.7 0.8 0.9
* Significance at p < .05 between the two groups. Time (sec)

from the ANOVA comparing the 2 groups. These variables are

described in the following sections.
A typical force-time curve is shown in figure 2, which illus-
trates some of these parameters. The tangential force (Ft) repre- B
sents the portion of the total force that goes into propelling the 90
wheelchair. The radial force (Fr) represents the portion of the
80
total force directed from the pushrim toward the hub. Although
Fr does not contribute to forward momentum, a certain amount 70
of radial force is necessary to create friction between the hand
60
and the pushrim. Figure 3 depicts a representative propulsive
stroke from the non-wheelchair user group and from the wheel- "" 50
chair user group.
o 40 II i'''" %%
Peak force magnitudes represent the highest force level that o
the subjects generated in either the tangential or radial direction 30
while applying force to the pushiim. The time to reach the peak
value is indicative of the rate at which the force is developed.
Analysis of the critical variables from the force curves showed
20
10
//,-- -,% ,,,,,.
ff
that for peak tangential force (F,) and time to peak Ft there
0
-10
loo [ 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9
E ° Time (sec)
II
8O
Fig 3. Representative curves of (A) non-wheelchair users and (B) wheel-
chair users. One stroke from 1 subject shows the resultant force (F) in
6O relation to Ft and Fr.

40 were significant differences between both groups, with the non-

user group attaining a higher value in a shorter period of time.
2O Within groups, the nonusers exhibited no differences for either
parameter, while the wheelchair users demonstrated significant
differences for both variables. There were no significant differ-
13.1 0.2 0.3 0.4 0.5 ences between groups for either peak radial force (Fr) or time
Time t o to peak radial force. Within groups, peak Fr w a s significantly
',_ Impact 1 Time (sec)
different among subjects for both groups, but only the n o n -
~- Spike =1
I
wheelchair users exhibited significant differences for time to
I~ T i m e t o Peak Force reach peak Fr.
The peak hub moments (Mz) were not significantly different
I
between the 2 groups but the wheelchair users took significantly
I Propulsion Durat ion longer to reach peak moment (Mz). Wheelchair users were not
significantly different from each other for either variable, while
Fig 2. A typical Fv curve is depicted with the critical variables defined.
peak moment was the only one of the two significantly different
The impact spike represents the initial contact of the wheelchair user's
hand with the pushrim during the early part of propulsion. The peak among the nonusers.
force is the largest force level attained for any of the forces. The impact spike is the initial rise in a force curve and is

Arch Phys Med Rehabil Vol 77, September 1996

860 WHEELCHAIR PROPULSION KINETICS, Robertson
related to the wheelchair user striking the pushrim at the begin-
ning of the propulsion phase. Figure 2 shows a representation
of this value. The magnitude of the impact spike, determined
from the vertical force curves (Fy), were not significantly differ-
ent between groups (table 2). The time to impact spike was
significantly longer for the wheelchair users. The users were
not significantly different from each other, whereas the nonusers
were significantly different from each other.
The relationship between the amount of tangential and radial
force to the total force (F) may represent a measure of stroke
efficiency. 18'23In contrast to these previous determinations, the
ratios (equation 9) were calculated from squared measures of
the forces defined previously in equation 2.
Fr: Fd
~7 + ~ = 1
The maximum and mean ratios (radial and tangential) for
both groups are given in table 2. Both groups had larger ratios
for the tangential force (Ft) than for the radial force (Fr). The
average mean Fr ratio was .209 for the non-wheelchair users
and .222 for the users. The average maximum Fr ratio was .700
for both groups. Maximum Ft ratios were .999 for the nonusers
and .952 for the users. The mean Ft ratios were .728 and .791
for the wheelchair users and the nonusers, respectively. None
of the differences between groups were significant.
Figure 4 depicts a sagittal view of the pushrim with Fr, F,,
and F plotted at the PFA. Approximately every 10th value is
plotted from the beginning of the propulsive phase to the end.
Each graph represents the mean value for each group. These
graphs show how each group on average applies forces to the
pushrim at the PFA throughout the propulsion phase.
Figure 5 shows the average start and end of the propulsive
stroke plotted on a sagittal view of the pushrim. There were
significant differences between the start angle and the total angle
pushed between groups. The wheelchair users started the pro-
pulsion phase at a significantly greater angle from the horizontal
position than did the nonusers, and they pushed through a
greater range. The end angle was not significantly different.
B
Fig 4. Mean forces for (A) non-wheelchair users and (B) wheelchair us-
ers, plotted at the point of force application (PFA): Fr, radial force; It,
tangential force; F, resultant force.
Arch Phys Med Rehabil Vol 77, September 1996
Start of p r o p ~
push r i ~ ' ~ End of propulsion
%~
Start of p r o p u l s i o n . ~ 1 0 6 deg
(9)
-n~dd
a deg
push ri of propulsion
Fig 5. The mean start and end angles for the propulsion stroke for (A)
non-wheelchair users and (B) wheelchair users. Angles are referenced
to 0 °, horizontal.
Net Joint Forces and Moments
Net joint forces and moments represent the overall forces
seen across joint structures. They represent a combination of
inertial factors, muscle contractions, and segmental weights. For
this study net joint moments and forces were determined at the
3 joints of the upper extremity. In this study, net joint reaction
forces were not analyzed at each joint as the inertial contribution
to these forces was found to be negligible. The horizontal and
vertical forces seen at the pushrim were the major contributors
to the net joint reaction forces, and analysis of these forces at
the pushrim reflects what is occurring at the joints. The tangen-
tial and radial pushrim forces were presented earlier and repre-
sent how effectively an individual applies force to the pushrim.
The peak magnitude of the Fy force was shown to be signifi-
cantly larger for the non-wheelchair users (81.9 _+ 11.4) than
for the wheelchair users (56.9 +_ 15.6). This force is seen as a
net joint reaction force at the shoulder and will be discussed as
a potential injury causing mechanism.
Table 3 lists the mean and maximum net joint moments at
each joint. The largest moments for both groups were seen at
the shoulder joints, which were significantly larger (p < .05)
than either the elbow or wrist moments. The non-wheelchair
users exhibited significantly larger moments at both the elbow
and shoulder when compared to the wheelchair users.
Figure 6 depicts ensemble curves and 5 strokes of 1 subject
from each group for joint moments at the wrist, elbow, and
shoulder. As can be noted, there were considerable differences
in the moments based on level of experience using a wheelchair,
particularly at the shoulder and elbow joints.
DISCUSSION
Wheelchair propulsion is a unique way of utilizing the upper
extremity to provide mobility. Most tasks performed by the
upper extremity are manipulative in nature. That is, the upper
extremity is used to place the hands in a position where objects
can be handled. Wheelchair propulsion requires the upper ex-
tremity to produce repeated, forceful movements. A number of
studies have shown that high-force high-repetition tasks result
 WHEELCHAIR PROPULSION KINETICS, Robertson
Table 3: Mean and Maximum Values for Joint Moments at Each Joint for Each Group
Wrist
Average Max
Moment Moment
Non-wheelchair users
Mean -.15 2.29
SD (1.18) (1.01)
Wheelchair users
Mean 1.91 5.78
SD (3.70) (6.95)
Average and maximum moments are grand means determined from the means of each subject within a group.
* Significant differences (p < .05). The maximum shoulder moment for both groups was significantly larger (p < ,05) than the moments at either the
elbow or the wrist.
in injury to upper extremity joints and the nerves that transverse
them. 32-36To determine the cause of injury, we must understand
the forces and moments associated with injurious tasks. Manual
wheelchair users experience a high incidence of upper extremity
injuries, ~-9 which, in large part, may be attributable to how
forces are applied to the pushrim during propulsion. This article
assesses the pushrim and joint forces necessary to propel a
wheelchair. In addition, the differences among inexperienced
and experienced wheelchair users and the implications for injury
are discussed.
The magnitudes of the pushrim and upper extremity forces
found in this study were comparable to those reported in previ-
ous studies. We showed that peak pushrim forces averaged
between 66 and 95N tangentially and 34 to 39N radially for
a propulsion speed of approximately .75m/sec. Average peak
shoulder, elbow, and wrist moments were -34.9, -21.3, and
2.3Nm, respectively, for the non-wheelchair users and -19.6,
-12.3, and 5.8 Nm, respectively, for the wheelchair users. Ver-
tical forces at the pushrim averaged 82N for the nonusers and
57N for the users. Veeger and coworkers 37 reported peak verti-
cal forces between 88 and 152N for propulsion speeds between
1.11 and 1.67m/sec. Joint moments were between 22 to 36Nm
for the shoulder, 5 to 10Nm for the elbow and 4 to 9Nm for
the wrist. Su and associates~s found smaller shoulder moments
(6 to 11Nm) for their subjects but the test was performed on a
treadmill at a slower speed. Rodgers and coworkers ~7 found
shoulder moments which were higher, but these subjects pushed
at a slightly faster speed (.97m/sec) and a smaller pushrim was
used.
Our analysis focused on Ft, the portion of the force driving
the wheelchair forward, and Fr, the portion of the force directed
radially. Fr, although not involved in moving the wheelchair,
is required to create friction between the hand and the pushrim.
We found that inexperienced and experienced wheelchair users
differed considerably in how they applied forces to the pushrim.
Generally, wheelchair users developed lower peak forces, the
peaks were reached later in the propulsive cycle, and peak forces
were maintained for longer periods of time. This is illustrated
in figure 3. Users also were found to apply propulsive forces
for a longer period of time while maintaining the same speed
of propulsion as the nonusers. Significant differences between
the two groups were found in peak Ft, the time to peak F~, and
peak vertical force, or force directed straight down using a
global reference frame. The magnitude of tangential force was
related to experience, with nonusers developing larger peak Ft
and reaching these peak values in a shorter period of time. Peak
tangential forces were larger than peak radial forces for both
groups.
Investigating Fr and F, highlights important components of
pushrim forces. Many investigators have assumed that nontan-
gential forces are negligible and thus omitted them. ~7This omis-
sion ignores an important aspect of propulsion biomechanics
861
Elbow Shoulder
Average Max Average Max
Moment Moment Moment Moment
-10.31 -21.31" -16.89 -34,87*
(2,76) (3.88) (4.16) (5.00)
-4.61 - 12.31" -8.67 -19.60"
(4.02) (2.62) (4.29) (5.56)
that helped distinguish wheelchair users from nonusers in this
study and may help explain injury mechanisms. From an effi-
ciency standpoint, the greater proportion of force directed tan-
gential to the pushrim, the greater the moment developed at the
hub. Some Fr is required to provide friction such that a Ft can be
produced. However, individuals who apply large nontangential
forces will require larger total forces to maintain the same veloc-
ity. This has implications for injury in that if larger forces are
required at the pushrim then greater joint forces and moments
are developed. How much Fr is required is dependent on the
pushrim-hand frictional characteristics and the requirements of
the wheeling task, ie, going faster or slower, going up and down
ramps, turning, and stopping and starting. Our study has shown
that there are differences in tangential force production depen-
dent on user experience and that within groups, large amounts
of variability existed within the stroke itself.
Veeger and colleagues ~s'2°'23'24'37have described the impor-
tance of tangential versus total force produced. They developed
a measure, the fraction of effective force (FEF), which related
a pure tangential force (Mz/R) at the pushrim to the total force.
This measure was used to describe how effective an individual
was in applying forces to the pushrim. In agreement with our
study, they found that subjects generally had a fraction of effec-
tive force that was low. They attributed this to the constrained
motion required by not only placement of the users body in a
seated position, which has a particular orientation to the push-
rim, but also the requirement that the user apply forces to a
circular, rigid system. In the present study we calculated ratios
relating F, and Fr to the total force. Our calculations are based
on equation 9. We found that the mean Fr stroke ratios averaged
approximately 22% while the mean F~ stroke ratios averaged
between 73% and 79%. The ratios indicate that the radial force
as a percentage of the resultant force averaged over 20% for
the propulsive phase and peaked at close to 70%.
There are other components of the propulsive stroke that
helped distinguish wheelchair users from nonusers and may
help explain injury mechanisms. Figure 3 depicts force-time
curves from one subject in each group. This figure demonstrates
the differences between groups in how they apply forces to the
pushrim. Users had lower peak forces and applied force over a
longer period of time. Lower peak forces coupled with longer
stroke time decreases exposure of joints to harmful forces with-
out decreasing speed. These plots also show that the n o n -
wheelchair users had a more distinct impact s p i k e - - t h e first
peak in the force curve. This is the point in time when the
individual first makes contact with the pushrim or very shortly
thereafter. A rapidly developed force at pushrim contact may
expose joint structures to rapid rates of loading which will
ultimately produce trauma. Another important aspect of pushrim
forces may be the point of force application (PFA). Figure 4
shows each of the major force components and where on the
Arch Phys Med Rehabil Vo! 77, September 1996
862 WHEELCHAIR PROPULSION KINETICS, Robertson

A
Ensemble

i5t
::f E'b°w I0~'--. Shoulder

.15(]t . . . . . . . . . .
0 10 20 30 40 50 60 70 80 90 100
:I . . . . 7 /
0 10 20 30 40 50 60 70 80 90 100
2 0 10 20 30 40 50 60 70 80 90
% Propulsion % Propulsion % Propulsion
Subject I

25
.-. 20 Wrist to bow ,0t Shoulder

-10
-I0
-20 °

-i0
-10 -5
0 0.[ 0.2 0.3 0.4 0,5 0.6 0.7 0.8 0.9 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9
Time(see) Time(see) Time(sec)

B
Ensemble

" - 2( Wrist Elbow . Shoulder

.., 1( j "',
0 -1C ,..--, ,,"

0 -2C Fig 6, Net joint moment curves

for the wrist-left, elbow-middle,
-3( and shoulder-right for (A) non-
-1( {0 20 30 40 50 60 70 80 90 100 10 20 30 40 50 60 70 80 90 100 10 20 30 40 50 60 70 80 90 100 wheelchair users and (B) wheel-
% Propulsion % Propulsion % Propulsion chair users. Ensemble curves
represent the mean and stan-
Subject 7 dard deviation of the moments
for each joint across all subjects
plotted as a percentage of the
~ , 20 Wrist i0 w propulsion stroke. Individual
15 subject curves represent 5
,0 -10: strokes plotted against time.
The individual graphs show the
o 5 40
time-varying relationships of the
-20 -30 joint moments, and the ensem-
Nq -40 ble curves demonstrate overall
-I( -3 joint moment mean values and
-50
0.1 0,2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 0 0.1 0.2 0.3 0,4 0.5 0.6 0.7 0.8 0,9 standard deviations for the en-
Time (see) Time(see) Time(see) tire group,

pushrim these forces are applied throughout the propulsion
phase for both groups. Other studies have assumed that the 2nd
or 3rd MP is coincident with the PFA. 24 The PFA may be a
way of distinguishing differences in the way individuals apply
force to the pushrim that could be used to identify potentially
harmful stroke mechanics. A further examination of all these
variables is warranted, particularly for larger numbers of wheel-
chair users with different levels of impairment and for different
conditions of propulsion including speed changes, directional
c h a n g e s , and c h a n g e s in resistance.
Inertial effects w e r e f o u n d not to c o n t r i b u t e significantly to
j o i n t reaction forces. This i m p l i e s that forces at the p u s h r i m
w e r e the m a i n contributor to the reaction f o r c e s seen at the
joints. This is in a g r e e m e n t with o t h e r investigators. 24 It is ex-
p e c t e d that at h i g h e r s p e e d s the larger inertial c o m p o n e n t w o u l d
increase the forces across the shoulder. T h e Fy c o m p o n e n t o f
the p u s h r i m force is directed vertically with r e f e r e n c e to the
global c o o r d i n a t e system. T h e s e f o r c e s a v e r a g e d 82N for n o n -
w h e e l c h a i r users and 5 7 N for users; t h e s e results w e r e signifi-
cantly different. T h e s e are h i g h forces, e s p e c i a l l y w h e n c o n s i d -
ering that the subjects p u s h e d at a m o d e r a t e test speed. Fy forces,
w h e n t r a n s m i t t e d to the shoulder, h a v e a t e n d e n c y to drive the
h e a d o f the h u m e r u s into the a c r o m i o n , Figure 7 illustrates the
p o s i t i o n o f the j o i n t s e g m e n t s in r e l a t i o n s h i p to the p u s h r i m
w h e n p e a k vertical f o r c e w a s acting at the s h o u l d e r for both
groups. This u p w a r d d r i v i n g f o r c e m a y p l a c e the s h o u l d e r at
risk for the d e v e l o p m e n t o f rotator c u f f tears or i m p i n g e m e n t
syndromes. 3

Arch Phys Med Rehabil Vol 77, September 1996

 WHEELCHAIR PROPULSION KINETICS, Robertson
Shoulder
N 3. Bayley JC, Cochran TP, Sledge CB. The weight-bearing shoulder,
PushJ
shrim
Fig 7. Stick figure representation of position of the arm, forearm, and
hand when the peak vertical reaction force (mean value) was attained
by (A) non-wheelchair users and (B) wheelchair users. The mean start
position (x) and end position (o} are indicated. The peak value for the
non-wheelchair users was reached at 70% into the propulsion phase,
whereas for the wheelchair users this peak was reached at 62%.
Our study has shown that discrete variables derived from the
pushrim force-time curves can discriminate between wheelchair
users based on experience using a wheelchair. This has im-
portant implications for studies that use n o n - w h e e l c h a i r users,
but in addition, the individual who is new to the use of wheel-
chairs may have stroke mechanics that subject the joints of the
upper extremity to large forces. The pushing strategy employed
by the wheelchair user may have been developed in order to
place as low a level of stress on the upper extremity as possible
while still accomplishing the task. Part of this strategy appears
to be that high peak forces developed rapidly are avoided in
conjunction with a longer push stroke.
Additionally, we have shown that the nontangential compo-
nent of the resultant force (Fr) should be considered when as-
sessing wheelchair propulsion kinetics. It may be indicative of
misdirected application of the force to the pushrim or indicate
that the user-wheelchair interface is less than o p t i m a l - - s u f f i -
cient friction must be attained by a large normal force to the
pushrim surface or the person is inappropriately seated in the
wheelchair in relation to the pushrim. Much more work must
be completed on assessing pushrim forces and the concomitant
joint moments and forces in order to develop an understanding
of the factors which dictate whether an individual will sustain
a propulsion injury. Three-dimensional pushrim forces in rela-
tionship to the kinematics of the propulsive stroke should be
studied in detail along with concomitant net joint forces and
moments, The influence of seating position, speed of propulsion,
different conditions of propulsion such as speed changes, ramps,
and directional changes, and different levels of impairment must
be investigated to determine the causes of the high incidence
of injuries experienced by manual wheelchair users.
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Suppliers
a. Sunrise Medical, Inc., Quickie Wheelchairs, 2842 Business Park Av-
enue, Fresno, CA 93727.
b. Peak Performance Technologies, Inc., 7388 South Revere Parkway,
Suite 601, Englewood, CO 80112.