Clinical Biomechanics 27 (2012) 255–262

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Clinical Biomechanics
journal homepage: www.elsevier.com/locate/clinbiomech

Simulated effect of reaction force redirection on the upper extremity mechanical

demand imposed during manual wheelchair propulsion
Joseph M. Munaretto a,⁎, Jill L. McNitt-Gray a, b, Henryk Flashner c, Philip S. Requejo d
a
Department of Biomedical Engineering, University of Southern California, Los Angeles, CA, USA
b
Department of Biological Sciences, University of Southern California, USA
c
Department of Aerospace & Mechanical Engineering, University of Southern California, USA
d
Rehabilitation Engineering Program, Rancho Los Amigos National Rehabilitation Center, Downey, Los Angeles, CA, USA

a r t i c l e i n f o a b s t r a c t

Article history: Background: Manual wheelchair propulsion is associated with overuse injuries of the shoulder. Reaction force
Received 27 April 2011 redirection relative to upper extremity segments was hypothesized as a means to redistribute mechanical load
Accepted 3 October 2011 imposed on the upper extremity without decrements in wheelchair propulsion performance.
Methods: Two individuals performed wheelchair propulsion under simulated inclined (graded) conditions using
Keywords: self-selected control strategies. Upper extremity kinematics and reaction forces applied to the wheel were quan-
Biomechanics
tified and used as input into an experiment-based multi-link inverse dynamics model that incorporates
Model simulation
Multijoint control
participant-specific experimental results. Reaction force direction was systematically modified to determine
Upper extremity the mechanical demand imposed on the upper extremity (elbow and shoulder net joint moments and net
Joint kinetics joint forces) during wheelchair propulsion. Results were presented as solution spaces to examine the upper
Net joint moment extremity load distribution characteristics within and between participants across a range of reaction force
Net joint force directions.
Wheelchair propulsion Findings: Redirection of the reaction force relative to the upper extremity segments provides multiple solutions
Paraplegia for redistributing mechanical demand across the elbow and shoulder without decrements in manual wheelchair
propulsion performance. The distribution of load across RF directions was participant specific and was found to
vary with time during the push phase.
Interpretation: Solution spaces provide a mechanical basis for individualized interventions that aim to maintain
function and redistribute load away from structures at risk for injury (e.g. reduce demand imposed on shoulder
flexors (reduce shoulder net joint moment) or reduce potential for impingement (reduce shoulder net joint force).
© 2011 Elsevier Ltd. All rights reserved.

1. Introduction independence and a decrease in quality of life (Ballinger et al., 2000,

Manual wheelchair propulsion (WCP) is an effective form of wheeled
mobility for individuals with spinal cord or lower extremity impairments
as it allows for greater independence and participation in the community.
Use of a manual wheelchair also preserves upper extremity strength and
embeds cardiovascular conditioning as part of activities of daily life, in
contrast to more costly powered wheelchairs. The mechanical objective
of the WCP task requires sufficient tangential force applied at the hand/
rim interface to accelerate and regulate the momentum of the body/WC
system (Boninger et al., 1997, Veeger et al., 1992). The repetitive nature
of WCP exposes the upper extremity (UE) to repetitive loading that can
lead to acute and overuse shoulder pain and injuries resulting in loss of
⁎ Corresponding author at: 3560 Watt Way, PED 107, University of Southern California,
Los Angeles, CA, USA, 90089-0652.
E-mail address: jmunaretto@gmail.com (J.M. Munaretto).
Curtis et al., 1999, Mercer et al., 2006, Subbarao et al., 1995). Experimen-
tal results indicate that there is more than one solution to satisfy the
mechanical objective of the WCP task (Boninger et al., 2002, Dallmeijer
et al., 1994, Masse et al., 1992, van der Woude et al., 2001, Veeger et al.,
1989). Knowledge of the advantages and disadvantages of specific WCP
techniques can guide clinicians in an evidence-based decision process
for rehabilitation.
Optimal interaction between the user and wheelchair during WCP is
needed to maintain performance without increasing the risk of injury.
Previous research with goal-directed tasks has found that alteration of
reaction force orientation relative to lower extremity segments redis-
tributes load across joints (Mathiyakom et al., 2005, McNitt-Gray
et al., 2001). In WCP, maintaining the tangential component of the rim
force while redirecting the resultant force provides a means for redistri-
bution of mechanical loading across the upper extremity without a
decrement in WCP task performance (Rozendaal et al., 2003). Previous
modeling of WCP across force directions has evaluated optimal force

0268-0033/$ – see front matter © 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.clinbiomech.2011.10.001
256 J.M. Munaretto et al. / Clinical Biomechanics 27 (2012) 255–262

direction based on a cost function (Rozendaal and Veeger, 2000), load- follow the generalized Newton-Euler ‘up the chain’ inverse dynamics
ing across force directions when force magnitude is fixed (Desroches method. For both segments beginning with the forearm:
et al., 2008), and muscle activity between several force directions (Ran-
kin et al., 2010). Examination of ways to maintain functional perfor- ∑Fx ¼ maxCM
mance (e.g. maintain tangential force applied to wheel) without RxP ¼ maxCM  RxD ð1Þ
exceeding the existing capacity of the musculoskeletal system has RyP ¼ mayCM þ mg  RyD
been largely overlooked.
Proposed modifications in load distribution may need to consider
∑Mz ¼ IzCM αzCM
an individual's capacity to generate force. Preservation of segment
MzP ¼ IzCM αzCM  MzD  RxP :ðyP  yCoM Þ þ RyP :ðxCoM  xP Þ ð2Þ
and joint kinematics while redirecting force allows the WC user to
generate force at their preferred muscle lengths and velocities. In ad- þRxD :ðyCoM  yD Þ  RyD :ðxD  xCoM Þ
dition, WC users have different upper extremity segment properties
and propel the chair in unique segment configurations relative to m segment mass
their wheelchair (Gutierrez et al., 2005, Hughes et al., 1992, Kotajarvi axCM segment acceleration in x direction
et al., 2004, Masse et al., 1992, Mulroy et al., 2005, Richter, 2001). As RxP reaction force acting on the proximal end of segment in x
such, these participant-specific factors need to be incorporated in the direction
process of identifying effective means for an individual WC user to re- RyD reaction force acting on the distal end of segment in the y
distribute load during WCP. Simulations using an experimentally- direction
motivated dynamic multilink model can be used to incorporate g gravity constant
these factors unique to each individual when determining causal rela- IzCM Center of mass (CM) inertia about the z-axis
tionships between force direction and load distribution. αzCM CM angular acceleration about the z-axis
In this study, our aim was to determine the effect of reaction force MzP moment acting on the distal end of the segment about the
redirection on the mechanical demand imposed on the upper extremity z-axis
in WCP using a 2D model. Force redirection was hypothesized to affect yP location of the proximal segment end in the y-direction
net joint moments (NJM) and net joint force (NJF) distribution between yCoM location of the segment CM in the y-direction
the shoulder and elbow joints when performing the same manual WCP
task. Loading distribution was hypothesized to be participant specific Starting with the reaction force acting at the wrist, the joint forces
and vary with time during the push phase. To test these hypotheses, at the elbow were calculated, followed by the net joint moment at the
force direction and magnitude were altered while experimental tan- elbow. These values were then applied to the upper arm segment to
gential force and WC user kinematics were maintained. A 2D inverse calculate kinetics at the shoulder joint (Fig. 1).
dynamic model was used to generate solution spaces of mechanical
demand. 2.1.2. Modifications in force direction
Since radial wheel force (FR) does not contribute to torque gener-
2. Methods ation about the wheel axis, it was varied. The tangential component is
kept the same as observed experimentally (Fig. 2).
2.1. Experimental The point of application of the reaction force was assumed to act at
the wrist position on the wheel at each instant in time. Relative to act-
Two male wheelchair users with spinal cord injury (SCI) volun- ing at a metacarpophalangeal joint, force location will shift several
teered to participate (Age: 42, 27 – Weight: 74.9, 63.5 – Injury Level:
T12, L2 – Yrs Post Injury: 19, 8) in this study in accordance with the
Institutional Review Board at the Ranchos Los Amigos National Rehabil-
itation Center, Downey, CA. Use of only two participants was deemed
sufficient to show differences in simulation results while illustrating
how the modeling technique may aid clinicians at an participant-
specific level. The participants performed wheelchair propulsions on
an ergometer providing resistance that simulated pushing up an 8%
graded slope for 10 seconds. Participants were asked to maintain a
self-selected speed for the duration of each trial. Reflective markers
were used to monitor the 3D motion of the hand, forearm, upper arm,
and trunk segments. Three markers were also placed on the right
wheel to track wheel rotation (VICON, 50 Hz). Coordinates were rotated
into a (x,y,z) reference frame where x represented anterior/posterior
position, y represented superior / inferior position, and z represented
mediolateral position. The sagittal plane xy was oriented in global
space to symmetrically bisect the user. The force applied to the wheel- (xP,yP)
chair during WCP was measured using force transducers (SmartWheel
2500 Hz) in the radial, tangential, and mediolateral directions of the
wheel. The markers and upper extremity model used to estimate
(xCoM,yCoM)
wrist, elbow, and shoulder joint centers followed methods described
in (Rao et al., 1996). Force and kinematics were then projected into (xD,yD)
the sagittal plane for use in the 2D model.

2.1.1. Modeling
In order to more clearly illustrate the effects of force redirection, a
2D model was chosen. 2D models of WCP have previously provided in- Fig. 1. Net Joint Forces (NJF) and Net Joint Moments (NJM) acting on the forearm and
sight (Guo et al., 2003, Richter, 2001).The equations of motion used upper arm segments for an exemplar subject during manual wheelchair propulsion.
 J.M. Munaretto et al. / Clinical Biomechanics 27 (2012) 255–262
FR
R
FT (yW, yW)
FT
W
Fig. 2. The orientation of the resultant reaction force (θR) relative to the wheel is defined
relative to the radial direction (dotted line passing through wheel axis and wrist).
Reaction force (green vector) direction (θR) is systematically modified by keeping tangen-
tial component of the reaction force (FT) constant while the magnitude of the radial com-
ponent of the reaction force (FR) is varied. Simulation results reflect variations in θR
between 10° and 90°.
degrees on the wheel and UE moments several N-m (Cooper et al.,
1997), Wrist location was chosen for model simplicity as trends
with respect to changing force direction will still apply. Wrist angular
position on the wheel (θw) was calculated as
 
−1 yW
θW ¼ tan
xW
where xw and yw are the Cartesian coordinates of the wrist. The tan-
gential component of the reaction force (FT) applied to the wheel was
calculated using experimentally measured reaction forces as
FT ðt Þ ¼ Fy ðt Þ cosθW ðt Þ−Fx ðt Þ sinθW ðt Þ
where FX and FY are the components of the experimentally measured
reaction force in the global frame acting on the wheel. The direction
of the force acting on the WC user in the sagittal plane of the global
reference frame, θG is given by
θG ¼ θW þ θR
where θR is the reaction force radial direction at the wrist / pushrim
interface (Fig. 2). The magnitude of θG, was allowed to vary to generate
an angle θR between 10° and 90°. The angle describing the medial-
lateral component of the force, φ (toward body is positive) was set to
0 for this study. At each instant in time, the resultant force magnitude
needed to generate the experimentally measured tangential force was
FT ðt Þ
Fmag ðt Þ ¼
sinðθW ðt Þ−θG Þ  cosðϕÞ
2.1.3. Simulations
Inverse dynamics calculations (Eqs. (1) and (2)) were performed
using the experimental kinematic data combined with varying reaction
force directions and magnitudes as described above. The horizontal and
vertical RF components were computed for each force angle
(10°b θG b 90°) during simulation. For each force angle, inverse dynam-
ics was used to determine NJM for the elbow and shoulder and for the
axial component of the shoulder NJF. In addition, the sum of the
257
magnitude of net joint moments (total NJM) at the elbow and shoulder
was computed as:
E S
J ¼ jτ jþjτ j ð7Þ
An additional simulation was performed to control tangential force
magnitude over time. The time-averaged value was computed and
used at all points in time in a quasi-static analysis for participant 2.
Radial force was still allowed to vary.
3. Results
Reaction force (RF) direction was found to affect NJM and net joint
force (NJF) distribution between the shoulder and elbow joints when
performing the same manual WCP task. Load distribution was found
to be participant specific and vary with time during the push phase.
Peak force for participants 1 and 2 occurs at 76% and 78% of the push
cycle, respectively (Fig. 3). At peak force, redirection of the RF at the
hand/pushrim interface resulted in participant-specific changes in me-
chanical loading of the upper extremity at peak force (Fig. 4). In general,
NJM and NJF values were highest when the RF angle was small (radial
direction). The NJM and NJFs then decreased as the RF angle increased
and increased again when approaching RF angles of 90°. Minimal
elbow and shoulder NJM occur at different RF angles (Fig. 4). For exam-
ple, at the peak force, the minimum elbow NJM occurred when the RF
was at 90° and the minimum shoulder NJM occurred when the RF
was at 53° for the first participant. At very high and low RF angles,
elbow and shoulder NJMs increase or decrease together. When the RF
is directed between these radial and tangential extremes, there is an in-
verse relationship between the magnitude and direction of the elbow
and shoulder NJMs. These trends are participant-specific. For example,
the minimum elbow NJM occurred when the RF was at 61° for partici-
pant 2 compared to 90° for participant 1 (Fig. 4).
ð3Þ
Load was found to be redistributed across the upper extremity as a
function of the orientation of the RF relative to the upper extremity seg-
ments. Maintaining a constant torque applied to the wheel alters the RF
magnitude and its moment arms relative to the forearm and upper arm
(FBDs in Fig. 4). For example, in Case 2, the RF and elbow NJF acts to ro-
tate the forearm clockwise therefore requiring an elbow flexor NJM. In
ð4Þ
s1
s2
0
Tangential Force (N)
ð5Þ
q5
-50
-100
ð6Þ
-150
0 20 40 60 80 100
% Push Phase
Fig. 3. Tangential component of reaction force (RF) applied to wheelrim during a
representative push phase for subject 1 and 2. Peak RF occurs at same instant as peak
tangential force.
258 J.M. Munaretto et al. / Clinical Biomechanics 27 (2012) 255–262
Fig. 4. Elbow NJM, shoulder NJM, and total NJM at peak force across range of θR for participants 1 (S1) and 2 (S2). UE orientation shown for two force directions: Case 1: θR = 30
(blue), Case 2: θR = 90 (red).
Case 1, the RF and elbow NJF acts to rotate the forearm counterclock-
wise therefore requiring an elbow extensor NJM. In Case 2, the elbow
flexor NJM and the elbow and shoulder NJFs work together to rotate
the upper arm clockwise requiring a shoulder flexor NJM. In Case 1,
the elbow and shoulder NJFs are larger but more aligned with the
upper arm to produce a small clockwise moment while the elbow
extensor NJM acts to rotate the upper arm counter-clockwise. Thus a
shoulder extensor NJM is needed.
Participant specific differences in joint kinetics were found to be
dependent on the orientation and magnitude of the RF relative to the
UE segments (Fig. 4). The rotation effect of a reaction force or net joint
force about the center of mass (CM) of a segment is the cross product
(r× RF) of the position vector (r) and RF or net joint force applied at
the end of the segment. If the RF is aligned with the segment, the rota-
tion effect of the force is relatively small because the moment arm of the
force in relation to the segment CM is small. The rotation effect of a force
increases as the magnitude and/or the moment arm increases. While at
similar elbow flexion angles, the direction of the shoulder / wrist vector
(SW) is more tangential in participant 1 than participant 2. A tangen-
tially directed force acting on participant 1 acts less posteriorly on the
forearm than it does for participant 2. A 30° from radial RF acts more an-
teriorly on participant 1 than participant 2. This results in a difference in
the moment arm relative to the forearm and upper arm between the
two participants and explains the differences in the loading distribution
between the participants.
The pattern of change in mechanical distribution due to force redirec-
tion is affected by position on the pushrim. From the middle to the end of
the push phase there is a clear trend in location of minimum NJM values
shifting from radial RF to predominantly more tangential RF direction
(Fig. 5). Locations of minimum NJM for participant 1 across time are
found at more tangential RF directions than those of participant 2 across
time. Since less propulsive force is generated, the mechanical demand is
lower in the beginning and end than middle of the push phase.
Mechanical demand (NJM) over the propulsion cycle changes with
orientation of the RF and NJF relative to the upper extremity segments
(r x RF) and the adjacent joint NJM (elbow). The magnitude of the
NJM depends on both the segment configuration and tangential force
magnitude. Each of these vary with time and as a result the NJM is likely
to vary with time. Simulation results using a fixed time-averaged tan-
gential force indicate that potential NJM and NJF loadings tend to be
higher earlier in the push phase as compared to later in the push
phase (Fig. 6). Minima of elbow, shoulder, and total NJMs tend to be
located in more tangential RF directions in the early push phase. They
then shift quickly to radial RF directions and finally trend back toward
tangential RF directions at the end of the push phase. Total NJM is high-
est across force directions at about 0.1 seconds and then decreases with
time.
Free body diagrams of early and late positions illustrate how orien-
tation of RF relative to UE segments changes throughout the push
phase (Fig. 7). When the wrist position on the rim is posterior relative
to top dead center (early phase), RF acts more posteriorly on the
upper extremity. As the push phase progresses, RFs increasingly act
more anteriorly to the CM of the forearm and upper arm segments.
These shifts in proximal and distal moments, created by the RF and
NJFs about the segment CM, affect the magnitudes and directions of
the elbow and shoulder NJMs across positions.
Changes in RF direction relative to the upper extremity segments
correspond to changes in UE orientation relative to the pushrim. From
early to late, the forearm changes from a radial to tangential alignment
with pushrim (Fig. 7). Forearm reorientation changes moment arm
magnitudes relative to the RF, which alters proximal and distal forces
and moments. For example, a tangentially directed RF creates a large
moment about the forearm CM in the early push phase and a low mo-
ment at the end of the push phase. At about 0.07 s, the forearm is per-
pendicular to the pushrim. Consequently a RF applied in the
tangential direction results in a maximal elbow NJM. From early to
late, the line passing through the shoulder and wrist (SW’ vector
Fig. 7) changes from almost directly opposing to perpendicular to al-
most directly in line with the tangential direction of the pushrim. Shoul-
der NJM is largest in the tangential direction at about 0.17 s than any
other time because the SW vector is almost perpendicular to the
pushrim.
 J.M. Munaretto et al. / Clinical Biomechanics 27 (2012) 255–262 259

θR S1 S2
Elbow NJM (Nm) Elbow NJM (Nm)
90 100 90
Sagittal Force Angle (deg)
80 90 80 70
80

Sagittal Angle (deg)

70 70 60
70
60 60 50
θR 60
50 50 50 40

40 40 40 30
30
30 30 20
20
20 20 10
10
0 10 0
0 0.1 0.2 0.3 0.4 0.5 0 0.05 0.1 0.15 0.2 0.25 0.3
Shoulder NJM (Nm) Shoulder NJM (Nm)
90 100 90

80 90 80 70
Sagittal Force Angle (deg)

80
70 60

Sagittal Angle (deg)

70
70
60 60 50
60
50 50 50 40

40 40
40 30
30
30 30 20
20
20 20
10 10

0 10 0
0 0.1 0.2 0.3 0.4 0.5
0 0.05 0.1 0.15 0.2 0.25 0.3
Total NJM (Nm) Total NJM (Nm)
90 100 90

80 90 70
80
Sagittal Force Angle (deg)

80
70
Sagittal Angle (deg)

70 60
70
60 60 50
60
50 50 50 40

40 40
40 30
30
30 30 20
20
20 20 10
10
0 10 0
0 0.1 0.2 0.3 0.4 0.5 0 0.05 0.1 0.15 0.2 0.25 0.3
Axial Shoulder NJF (N) Axial Shoulder NJF (N)
90 250 90
180
80 80
Sagittal Force Angle (deg)

200 160
70 70
Sagittal Angle (deg)

140
60 60 120
150
50 50 100

100 80
40 40
60
30 30
50 40
20 20 20
0 10 0
0 0.1 0.2 0.3 0.4 0.5 0 0.05 0.1 0.15 0.2 0.25 0.3
Time (s) Time (s)

Fig. 5. Between participant comparison (S1 vs S2) of joint kinetics (elbow, shoulder, and total NJM; resultant shoulder NJF), across time and θR). Black dots indicate experimental data.
260 J.M. Munaretto et al. / Clinical Biomechanics 27 (2012) 255–262

θR
Elbow NJM (Nm) Shoulder NJM (Nm)
90 90

80 70 80 70
Sagittal Force Angle (deg)

70 60 70 60

60 50 60 50
θR 50 40 50 40

40 30 40 30

30 20 30 20

20 10 20 10

10 0 10 0
0 0.05 0.1 0.15 0.2 0.25 0.3 0 0.05 0.1 0.15 0.2 0.25 0.3
Total NJM (Nm) Axial Shoulder NJF (N)
90 90
180
80 70 80
Sagittal Force Angle (deg)

160
70 60 70
140
60 50 60 120
50 40 50 100

40 80
30 40
60
30 20 30
40
20 10 20 20
10 0 10 0
0 0.05 0.1 0.15 0.2 0.25 0.3 0 0.05 0.1 0.15 0.2 0.25 0.3
Time (s) Time (s)

Fig. 6. Simulation results (elbow, shoulder, and total NJM; resultant shoulder NJF) for participant 2 when keeping torque applied to the wheel constant throughout the push phase.
By fixing reaction force magnitudes over time, these figures give a sense of how potential loading varies between different kinematic positions.

4. Discussion tangential. RFs in increasingly tangential directions were associated

Simulation results from this study indicate that redirection of the
hand / rim reaction force relative to the upper extremity segments
provides a means to redistribute mechanical load across joints and
also to shift away from loads associated with pain without decrements
in performance (same torque applied to wheel). Model simulations
with a 2D inverse dynamic model using participant-specific experimen-
tal tangential force and kinematic data were used to determine upper
extremity NJMs and shoulder NJF while varying the magnitude of the
radial component of the reaction force. Load distribution trends were
found to vary during the push phase and were participant-specific.
These simulation results provide a mechanical basis for clinical deci-
sions regarding interventions that aim to redistribute load as a means
of avoiding overuse injury.
The results in this study are consistent with other modeling and
experimental studies that have researched effective force direction.
Simulation results indicate that as sagittal plane reaction force direction
varies the elbow, shoulder, and total NJM and shoulder axial NJF change.
Reaction forces oriented in radial directions resulted in high magni-
tudes of all variables since the magnitude of the RF increased as the
radial component increased. Elbow, shoulder and total NJM and shoul-
der NJF reached minimum magnitude at times the RF was directed in a
non-tangential direction. This finding is consistent with modeling
results obtained by (Rozendaal and Veeger, 2000) who found that the
preferred force direction, as defined by a cost / effect function, is not
with increases in the shoulder NJM, as reported by others (Bregman
et al., 2008, Desroches et al., 2008, Rankin et al., 2010). While not mea-
suring energy expenditure directly, these simulation results are consis-
tent with experimental studies that have found higher energetic costs
associated with trying to direct the reaction force more tangentially
(de Groot et al., 2002, Kotajarvi et al., 2006).
Though the model used in this study provides sufficient complexity
to illustrate the sensitivity of joint kinetics (NJM and NJF) during WCP to
redirection of reaction forces, there are several limitations. Interpreta-
tion of simulation results needs to consider that the 2D model neglects
out-of-plane mediolateral kinematics and forces. In reality, both kine-
matics and force are 3D during WCP (Koontz et al., 2002). The general
trends in loading distribution as a function of force direction are
expected to be consistent although more complex when moving to
3D. In a related study, we quantitatively examined how 3D kinematics
and forces affect the distribution of mechanical load during WCP. Simu-
lations in this study assumed that the RF was applied directly to the
wrist and thus neglected the contribution of grip and wrist NJMs on
WCP mechanics. Variations in medial-lateral forces may affect simula-
tion results in that the mediolateral component of the RF alters the mo-
ment arm between the RF and each segment's CM. Simulation results
are expected to be especially sensitive when the RF is oriented in
more radial directions since the RF tends to be higher and more sensi-
tive to moment arm magnitude. Muscle activation patterns used by an
individual required to generate the shoulder and elbow joint kinetics
 J.M. Munaretto et al. / Clinical Biomechanics 27 (2012) 255–262
Early Push Phase Free Body Diagram of Force
Redirection
SW’
Shoulder NJM
Elbow NJM
Late Push Phase Free Body Diagram of Force
Redirection
SW’
Shoulder NJM
Elbow NJM
Fig. 7. Early vs late push phase free body diagrams for θR = 30 (radial, blue) and θR = 90
(tangential, red). Same RF directions relative to wheel yield different UE kinetics for
different segment orientations.
under each simulated condition are expected to vary with muscle force,
length, velocity and levels of coactivation (Erdemir et al., 2007). As a
result, we have elected to limit the current discussion of load distribu-
tion at the net joint force and net joint moment level.
In WCP, mechanical loading is affected by 1) reaction force direction
2) relative orientations of the upper extremity segments (forearm and
upper arm, i.e. elbow flexion) and 3) orientation of the UE relative to
the pushrim (i.e. shoulder/wrist axis relative to tangential direction). All
three mechanisms can alter NJM and NJF loading across the elbow and
shoulder joints. The implications of RF direction on load distribution
require consideration of the kinematic context in which the RF is generat-
ed since it varies between participants and with time (e.g. throughout the
push phase). As such, the effects of force direction are discussed in
relation to both local orientation (2) and global orientation (3).
Our results indicate that changing the orientation of the reaction
force relative to upper extremity segments changes the magnitudes
and ratios of the elbow and shoulder NJMs and NJFs. Changes in me-
chanical distribution have been found in other tasks such as landings
(McNitt-Gray et al., 2001), diving (Mathiyakom et al., 2007), and activ-
ities of daily living (Mathiyakom et al., 2005). Force direction affects
elbow NJM directly through orientation of the force relative to the seg-
ment CM. A force directed posterior to the forearm CM requires a flexor
elbow NJM, while a force directed anterior requires an extensor elbow
NJM. Elbow flexor/extensor NJM created opposing extensor / flexor mo-
ment acting at the distal end of the upper arm segment. The reaction
forces acting at the proximal and distal ends of the upper arm change
in magnitude and direction across handrim force directions, and the
interaction between the proximal and distal forces and the distal mo-
ment (also changes with force direction) will determine the shoulder
NJM. Given the same force magnitude and direction relative to the fore-
arm, shoulder NJM changes with upper arm orientations (amount of
elbow flexion). As the upper arm shifts from parallel (extended
elbow) to perpendicular relative to the forearm, the force direction
that minimizes shoulder NJM shifts anteriorly away from the forearm.
Therefore, participant specific and push phase differences in relative
orientations of the upper extremity segments alter loading distribution
patterns. Participants operating at different elbow flexion angles at peak
force may change the effect of force redirection on load distribution.
261
Similarly, different elbow angles across the push phase could alter effect
of force direction on loading.
Loading distribution in WCP is affected not only by force direction
relative to segment orientation but also by UE orientation relative to
the pushrim. In whole body tasks, changes in force direction and / or
segment configuration must satisfy whole body constraints of force di-
rection relative to the center of mass (CM) (Mathiyakom et al., 2005). A
different constraint is found in WCP as RF direction and magnitude
must also generate a specific tangential force component relative to
the pushrim. As force is directed more radially, the magnitude must in-
crease so that the tangential component remains the same to maintain
performance (Fig. 7). The orientation of the arm relative to the tangen-
tial and radial directions alters both force magnitudes and moment
arms, which affects loading distribution during WCP. RF near the radial
direction creates high loads regardless of moment arm magnitudes
since force magnitude needs to be extremely large in order to maintain
the tangential component of the RF. The two participants used in this
study had similar elbow flexion at peak force, but different loading dis-
tributions because the orientation of the arm relative to the pushrim
was different (Fig. 4). The loading effect of changing arm orientation rel-
ative to the pushrim was also evident between early and late push
phase instances for participant 2 (Fig. 7).
Modifications in the local and global orientations of the upper arm
collectively affect loading distribution that occurs across the propulsion
phase. Mechanical loading (at a given tangential RF) is relatively large at
the start of the propulsion phase because the upper arm is almost per-
pendicular to the forearm and the UE orientation relative to the push-
rim increases the moment arm magnitudes across force directions. If
“pulling” forces were simulated, loading may be reduced but this sce-
nario is not practical for many populations of WC users (Lamberg and
Friden, 2007). At the end of the push phase, upper arm and forearm seg-
ments are more parallel and aligned with the pushrim tangential direc-
tion, so both moment arms and force magnitude are reduced. Force
direction, local UE orientation, and UE orientation relative to tangential
direction all must be considered when evaluating load distribution so-
lutions during WCP.
Using an experimentally motivated inverse dynamic model to per-
form force direction sensitivity studies may provide clinicians with in-
sights into current WCP techniques. The solution spaces provide a
template for making decisions on how to attempt to redistribute load
via force redirection. For example, at peak force, participant 1 was
directing the RF at about 80° from the radial (Fig. 5). However, lower
shoulder NJM could be achieved if the RF was directed more radially
to about 50° (Fig. 4). Conversely, to reduce the axial component of the
shoulder NJF in participant 2, the RF should be directed more tangen-
tially from about 45° to 70° relative to radial direction. Our results indi-
cate that decisions on how to shift an individual within a solution space
must consider the kinematic context of force generation. WCP kinemat-
ics used by individuals may appear different but the joint kinetics indi-
cate that they are experiencing comparable loading distribution
conditions. The solution spaces generated using simulation results
also reflect the fact that load distribution changes at different wrist po-
sitions on the wheel, even if the reaction force is kept in the same direc-
tion relative to the pushrim. The results of this study provide better
understanding of how elbow and shoulder loads vary over different
RF directions and segment configurations in the push phase.
Using an experimentally motivated model to perform force direc-
tion sensitivity studies provides clinicians a method to assess current
WCP techniques in the context of mechanical loading and association
with pain / injury. The solution spaces provide a template for clinical in-
terventions that aim to maintain WCP performance and redistribute
load. Our results indicate that decisions on how to shift an individual
within a solution space must consider the participant-specific kinematic
context of force generation. Incorporating both experimental force an
kinematics into the model allows clinicians explore feasible options be-
fore intervention and tailor treatment specific to each participant.
262 J.M. Munaretto et al. / Clinical Biomechanics 27 (2012) 255–262
Acknowledgements
Sara Mulroy, Director of the Pathokinesiology Lab, and her research
team at the Rancho Los Amigos National Rehabilitation Center for their
contributions and feedback throughout the project.
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