The rationale for and efficacy of surgical intervention for electrodiagnostic-negative cubital tunnel syndrome.

Because conservative management of McGowan grade 1 cubital tunnel syndrome (symptoms only) may be successful in a high percentage of patients, normal electrodiagnostic studies and the absence of intrinsic muscle weakness or decreased sensation or both may be viewed as contraindications to operative intervention. Because the results of surgery are known to be inferior once objective motor weakness and abnormal 2-point sensory discrimination (McGowan grades 2 and 3) develop, however, we advocate surgical intervention for patients with symptoms only, even when electrodiagnostic studies are normal. We enrolled 16 patients (18 elbows) with McGowan I cubital syndrome who underwent in situ ulnar nerve release and medial epicondylectomy. Paresthesias resolved in all cases, and both elbow range of motion and grip strength returned to normal in 17 of 18 elbows. The elbow flexion test resolved in all cases, and a Tinel's sign was present at final review in 5 elbows (28%). One patient required another operation to address a neuroma of a posterior branch of the medial antebrachial cutaneous nerve, but additional morbidity was not identified after objective review and patient self-assessment.

Analysis of vibrations induced during wheelchair propulsion.

Little is known about how dynamic acceleration affects wheelchair-rider comfort. The current study was to test both the operation of an instrumented wheelchair by a wheelchair user over a Simulated Road Course (SRC) and the operation of the same instrumented wheelchair during normal daily activities (a field test) by test subjects. Sixteen subjects participated in the protocol. A SRC allowed collection of data from wheelchair users traversing obstacles similar to those experienced by a typical wheelchair user. The SRC consisted of eight obstacles fixed rigidly to a flat concrete surface. The field test began after the conclusion of the SRC test. Transfer functions were derived for all 16 subjects. It is clear from the results that for the SRC, the acceleration at the wheelchair frame exceeded the 8-h "fatigue-decreased performance boundary." A vertical acceleration resonant peak was evident for eight of the subjects. The average for these peaks, when present, was 8.1 Hz. This frequency is higher than the 4-6 Hz resonant peak presented in the literature for a seated human subject. This discrepancy could be due to different levels of trunk control between wheelchair users in this study and ambulatory subjects used in the literature. Subjects and their wheelchairs were exposed to a few, high-acceleration events rather than consistent, small-magnitude accelerations during the field test. This study indicates that vibration may be a contributing factor to fatigue among manual wheelchair users, which could lead to injury.

Road loads acting on manual wheelchairs.

A barrier to performing more in-depth analyzes during the wheelchair design process is a lack of dynamic reaction force and moment data, and the instrumentation to collect this data. Instrumentation was developed to collect the dynamic force and moment data. New data collections methodologies and analysis techniques were implemented to facilitate computer-aided-engineering for wheelchair designs. Data were collected during standardized wheelchair fatigue tests, while driving over a simulated road course within a laboratory, and while driving in the community. Seventeen subjects participated in this study. Based upon the three test conditions, a pseudo-statistical distribution of the force and moment data at both a caster and rear wheel was developed. The key parameters describing the distribution and the extremums of the data (minima and maxima) were compared using analysis of variance. The results showed that the force and moment distributions and extreme values were similar for the both sets of human trials (i.e., simulated road course and field trials). However, the standardized testing (i.e., wheelchair fatigue testing) differed from both human trials. The force/moment data gathered during this study are suitable for inputs in finite element analysis and dynamic modeling. Our results suggest that the fatigue tests should be modified to change the magnitude and increase the frequency of the forces and moments imparted on the wheelchair. The data reported from this study can be used to improve wheelchair standards and to facilitate computer-aided-engineer in wheelchair design.

User assessment of manual wheelchair ride comfort and ergonomics.

OBJECTIVE: To examine wheelchair-user perceived ride comfort during propulsion and to compare the ride comfort of ultralight and lightweight manual wheelchairs. An ultralight wheelchair is defined as having a high degree of adjustability, whereas a lightweight wheelchair has minimal adjustability. DESIGN AND PARTICIPANTS: Repeated measures design of a sample of 30 community-dwelling manual wheelchair users evaluating 7 different manual wheelchairs over an activities of daily living course. SETTING: A rehabilitation engineering center. MAIN OUTCOME MEASURES: Subject ratings of perceived ride comfort and basic ergonomics while propelling over the activities of daily living course. Ratings were recorded for each wheelchair on individual tasks and for the course overall. RESULTS: The Invacare Action XT wheelchair was ranked best for both ride comfort and basic ergonomics. The ride-comfort scores (p < .05) and wheelchair ergonomics ratings (p < .05) for the ultralight wheelchair group were significantly different from those for lightweight wheelchair group. CONCLUSION: There are differences in perceived ride comfort and basic ergonomics between the designs of the wheelchairs (lightweight vs ultralight). Subjects perceived that ultralight wheelchairs were more comfortable and had better basic ergonomics than lightweight wheelchairs.

Evaluation of a manual wheelchair interface to computer games.

The sedentary lifestyle of many people with spinal cord injury (SCI) has lead to cardiovascular diseases being a major health concern. A suitable exercise program may help improve the SCI individual's cardiovascular fitness level. GAMEWheels is an interface between a custom wheelchair roller system and a computer that enables an individual to control computer video games by driving his or her wheelchair. The purpose of Phase 1 was to evaluate the design of the GAMEWheels system and to determine the type of computer video game that is likely to motivate wheelchair users to exercise. Phase 2 included physiologic testing of wheelchair users and the GAMEWheels system to investigate whether the system elicits an exercise training response. Thirty-five subjects were recruited to evaluate the GAMEWheels by playing three commercial computer games (Phase 1) and to identify the computer game that they would prefer to use when exercising. The feedback from Phase 1 was used with test subjects to verify that the GAMEWheels system elicits an exercise training effect (Phase 2). Phase 2 included 10 subjects using the GAMEWheels system to play Need for Speed II. During game play, physiologic data were collected and the subjects' oxygen consumption and heart rate were analyzed. Analysis showed that the GAMEWheels system induced nine subjects to reach their training zone, defined as 50% and 60% of their maximum oxygen consumption and heart rate, respectively. This study demonstrates that the GAMEWheels system elicits an exercise training response.

A unified method for calculating the center of pressure during wheelchair propulsion.

The measurement of the center of pressure (COP) has been and continues to be a successful tool for gait analysis. The definition of a similar COP for wheelchair propulsion. however, is not straightforward. Previously, a COP definition similar to that used in force plate analysis had been proposed. Unfortunately, this solution has the disadvantage of requiring a separate COP definition for each plane of analysis. A definition of the generalized center of pressure (GCOP) which is consistent in all planes of analysis is derived here. This definition is based on the placement of a force-moment system, equivalent to the force-moment system at the hub, on a line in space where the moment vector (wrench moment) is parallel to the force vector. The parallel force-moment system is then intersected with three planes defined by anatomical landmarks on the hand. Data were collected using eight subjects at propulsion speeds of 1.34 m/s and 2.24 m/s (1.34 m/s only for subject 1, 0.894 m/s and 1.79 m/s for subject 8). Each subject propelled a wheelchair instrumented with a SMARTwheel. A PEAK 5 video system was used to determine the position of anatomical markers attached to each subject's upper extremity. The GCOP in the transverse plane of the wrist formed clusters for all subject's except subject 2 at 1.34 m/s. The clustering of the GCOP indicates that the line of action for the force applied by the hand is approximately perpendicular to the transverse plane through the wrist. When comparing the magnitude of the moment vector part of the wrench with the moment of the force vector of the wrench about the hub, the wrench moment is approximately an order of magnitude smaller. This indicates that the role of the wrist for wheelchair propulsion is primarily to stabilize the force applied by the arm and shoulder.

Performance of selected lightweight wheelchairs on ANSI/RESNA tests. American National Standards Institute-Rehabilitation Engineering and Assistive Technology Society of North America.

OBJECTIVE: This study provides data for clinicians and wheelchair users to compare the durability, stability, and cost effectiveness of three different lightweight wheelchair models: the Everest & Jennings EZ Lite, the Invacare Rolls 2000, and the Quickie Designs Breezy. A second objective was to compare the results from this study to those published for ultralight and institutional depot wheelchairs. DESIGN: Randomized standards testing of three wheelchair models from each manufacturer (nine wheelchairs total). RESULTS: There were no significant differences (p > .05) in fatigue life, life-cycle cost, or static stability between the three models of lightweight wheelchairs (ie, EZ Lite, Rolls 2000, or Breezy). There were, however, significant differences (p < .05) in fatigue life among the lightweight wheelchairs of this study and the published results for ultralight rehabilitation wheelchairs and for depot wheelchairs. The lightweight wheelchairs had an average fatigue life greater than the depot wheelchairs but less than the rehabilitation wheelchairs. A depot-type wheelchair was defined as a manual wheelchair designed for hospital or institutional use. At lightweight wheelchair was defined as a manual wheelchair with minimal adjustments designed for individual or institutional use. An ultralight rehabilitation wheelchair was defined as a manual wheelchair designed for an individual's use as a long-term mobility aid. CONCLUSION: The three models of lightweight wheelchairs tested are substantially similar and their fatigue lives are significantly (p < .05) lower than rehabilitation wheelchairs. Ultralight rehabilitation wheelchairs are the most cost effective over the life of the wheelchair, costing 3.4 times less (dollars per life cycle) than depot wheelchairs, and 2.3 times less (dollars per life cycle) than the lightweight wheelchairs tested in this study.

Uncertainty analysis for wheelchair propulsion dynamics.

Wheelchair propulsion kinetic measurements require the use of custom pushrim force/moment measuring instruments which are not currently commercially available. With the ability to measure pushrim forces and moments has come the development of several dynamic metrics derived for analyzing key aspects of wheelchair propulsion. This paper presents several of the equations used to calculate or derive the primary variables used in the study of wheelchair propulsion biomechanics. The uncertainties for these variables were derived, and then numerically calculated for a current version of the SMARTWheel. The uncertainty results indicate that the SMARTWheel provides data which has better than 5 to 10% uncertainty, depending upon the variable concerned, at the maximum, and during most of the propulsion phase the uncertainty is considerably smaller (i.e., approximately 1%). The uncertainty analysis provides a more complete picture of the attainable accuracy of the SMARTWheel and of the degree of confidence with which the data can be recorded. The derivations and results indicate where improvements in measurement of wheelchair propulsion biomechanical variables are likely to originate. The most efficient approach is to address those variables in the design of the system which make the greatest contribution to the uncertainty. Future research will focus on the point of force application and examination of nonlinear effects.

Methods for determining three-dimensional wheelchair pushrim forces and moments: a technical note.

This technical note illustrates that some of the differences that have been reported regarding wheelchair propulsion may be due to the methods used to calculate key variables. Wheelchair ambulation is a very important form of locomotion that lacks a standard pushrim force and moment analysis system. We have developed tools for analyzing upper limb biomechanics during manual wheelchair propulsion. Among the tools is a system that allows the direct measurement of global coordinate forces F(x), F(y), F(z) and corresponding moments. The analytical techniques presented here allow calculation of radial (F(r)) and tangential (F(t)) forces, the determination of point of force application (PFA), and the moment applied by the hand (M(hz)). Our results show that the PFA can be calculated from kinetic data. Comparison of the PFA to the second metacarpophalangeal (MP) joint, calculated from kinematic data and used in previous studies, resulted in a 0.2 radian difference on average, with the PFA showing greater variation near the beginning and ending of the propulsion phase. Analysis of methods for calculating the applied tangential force showed that using the PFA provides a more accurate measurement of this force than the previous method of assuming negligible hand-moment contribution. The hand moment was compared using the calculated PFA and assuming the PFA was coincident with the second MP joint. Both methods provided similar results with a mean difference of 0.6 N x m. The methods presented in this paper provide a framework for analyzing wheelchair propulsion forces and moments.

Projection of the point of force application onto a palmar plane of the hand during wheelchair propulsion.

The objective of this study was to develop and test a method for projecting the pushrim point of force application (PFA) onto a palmar plane model of the hand. Repetitive wheelchair use often leads to hand and wrist pain or injury. The manner by which the hands grasp the pushrim and how the forces and moments applied to the pushrim are directed may contribute to the high incidence of pain and injury. The projections of the PFA onto the palmar surface model of the hand reside primarily within zone II. These results are in agreement with previous studies which have assumed the PFA to be coincident with one of the metacarpophalangeal (MP) joints. However, the results from three subjects show different PFA patterns within the palmar surface of the hand which can be related to each subject's propulsion pattern, and the PFA is not focused at a single MP joint. Projection of the world coordinates of the four hand marker system onto the palmar plane show the resolution to be within 3 mm, or one half the diameter of the passive reflective markers. The errors in the planar model assumption were greatest for the second and fifth MP markers. This was expected because as the hand grasp changes these markers do not remain coplanar. The results of this study indicate that new knowledge about how forces are applied by the hand onto the pushrim can be obtained using this method. This technical note provides insight into understanding the details within the kinetics of wheelchair propulsion and describes a technique for estimation of the PFA on the palmar surface of the hand. This technical note provides initial results from three different wheelchair users.

Determination of wheelchair dynamic load data for use with finite element analysis.

A methodology is introduced for the experimental determination of the dynamic loads which act on a wheelchair. A box frame wheelchair and a cantilever frame wheelchair were tested on an ANSI/RESNA curb-drop tester [1]. The accelerations of an ANSI/RESNA test dummy [1] were recorded with an array of 12 accelerometers mounted as four three-axis groups. Signal averaging was used to produce a composite dynamic load history. The dynamic loads were calculated from the acceleration data and the inertia of the test dummy using software written by the authors. These loads were imported into a finite element program (ALGOR) [5], [6] as load cases. A prototype carbon fiber design was then optimized through design and analysis iterations. The results of the acceleration data indicate that the curb-drop test produces an asymmetric loading scheme. One of the rear wheels hits the ground before the other, placing most of the dynamic load on one side of the wheelchair. The favored side appears to be fixed at the time of setup. Preliminary results are given for the design of a modular carbon fiber wheelchair using the finite element (FE) method. These results indicate, however, that the use of a static factor of safety is, in most cases, inadequate for the dynamic loads present in the curb-drop test.

Life-cycle analysis of depot versus rehabilitation manual wheelchairs.

The proper selection of a wheelchair requires making several critical decisions, not the least of which is what type of wheelchair is appropriate. The International Organization for Standards (ISO) continues to develop and refine wheelchair standards. Standards allow the objective comparison of products from various sources, permitting consumers or clinicians to assess wheelchairs with which they are not familiar by comparing test results. This study consisted of three components: 1) the comparison of fatigue test results with a planar ANSI/RESNA test dummy to a HERL contoured test dummy; 2) the comparison of fatigue test results for common depot versus common rehabilitation manual wheelchairs; and 3) the comparison of fatigue test results for manual rehabilitation wheelchairs with solid 8-inch casters versus those with pneumatic 8-inch casters. Rehabilitation wheelchairs lasted on average 13.2 times longer than the depot wheelchairs. Both types, tested with the standard ISO-ANSI/RESNA dummy, lasted on average 2.1 times longer than those wheelchairs tested using the contoured dummy. The three rehabilitation wheelchairs equipped with 8-inch pneumatic casters lasted on average 3.2 times longer than the 6 rehabilitation wheelchairs equipped with solid 8-inch casters. The depot wheelchairs cost about 3.4 times as much to operate per cycle or per meter than the rehabilitation wheelchairs. The rehabilitation wheelchairs tended to experience component failures, while the depot wheelchairs tended to experience frame failures. Our testing indicates that the tests in the ISO-ANSI/RESNA standards can relate design features to fatigue test results and durability. Rehabilitation wheelchairs tend to use higher quality materials and better manufacturing practices, and they provide greater mobility for wheelchair users. Purchasers and prescribers of wheelchairs should consider the life-cycle cost and not just the purchase price for wheelchairs.

Power wheelchair range testing and energy consumption during fatigue testing.

The range of a power wheelchair depends on many factors including: battery type, battery state, wheelchair/rider weight, terrain, the efficiency of the drive train, and driving behavior. The purpose of this study was to evaluate the feasibility of three methods of estimating power wheelchair range. Another significant purpose was to compare the current draw on pavement to current draw on an International Standards Organization (ISO) Double Drum tester at one m/sec. Tests were performed on seven different power wheelchairs unloaded, and loaded with an ISO 100 kg test dummy. Each chair was configured according to the manufacturer's specifications, and tires were properly inflated. Experienced test technicians were used for the tennis court tests, and treadmill tests. An ISO 100 kg test dummy was used for the ISO Double Drum test. Energy consumption was measured over a distance of 1500 m for each of the three test conditions. The rolling surface was level in all cases. Repeated measure analysis of variance (ANOVA) revealed a significant difference (p = 0.0001) between the predicted range at maximum speed for the three tests. Post hoc analysis demonstrated a significant difference (p < 0.01) in estimated range at maximum speed between the Double Drum test and the treadmill test, as well as between the Double Drum test and the tennis court test. Our results indicate no significant difference (p > 0.05) between the predicted range at maximal speed between the treadmill and tennis court tests. A simple relationship does not exist between the results of range testing with the Double Drum tester and the tennis court. An alternative would be to permit the use of a treadmill for range testing as simple relationships between all pertinent treadmill and tennis court range data were found. For the Double Drum tester used, the current demand is higher than under normal usage. This presents a problem as current is related to load torque in a power wheelchair. Hence, the Double Drum tester friction must be reduced. The predicted range for the tennis court test at maximum speed ranges from a low of 23.6 km to a high of 57.7 km. The range of the power wheelchair can be improved by the use of wet lead acid batteries in place of gel lead acid batteries.

Evaluation of methods for determining rearward static stability of manual wheelchairs.

Wheelchair standards have been under development for several years. A set of tests has been approved by the American National Standards Institute (ANSI) and by the International Standards Organization (ISO) but continue to be refined. Static stability is one of the indicators used to evaluate manual wheelchairs and is measured by placing a loaded wheelchair on a platform that is tilted until the wheelchair's front wheels lift off of the platform. Currently, if the wheelchair parking brakes slip, a block is placed behind the rear wheels and the tip angle is measured. The results for eight different wheelchairs with three load cases showed that the rearward tip angle for the block is significantly different (p < 0.05) from that with the brakes alone.