Objective To test the effectiveness of a high-dose home exercise/telerehabilitation program for manual wheelchair users who have a spinal cord injury (SCI) and determine whether the intervention would reduce pain and increase function, as we hypothesized. Design A pre-post trial with outcomes measured at 3 time points: baseline, postintervention (12wk), and follow-up (24+ weeks). Setting Subjects performed an exercise program at their homes using telerehabilitation for therapist monitoring of technique and exercise advancement. Baseline and postintervention data were collected at a motion analysis laboratory in a tertiary medical center. Participants A convenience sample of manual wheelchair users (N = 16, 3 women; average age, 41y; average time in a wheelchair, 16y) with shoulder pain (average pain duration, 9y) and mechanical impingement signs on physical examination. Interventions A 12-week home exercise program of rotator cuff and scapular stabilization exercises was given to each participant. The program included a high dose of 3 sets of 30 repetitions, 3 times weekly, and regular physical therapist supervision via videoconferencing. Main Outcome Measures Primary outcomes of pain and function were measured with the Wheelchair User's Shoulder Pain Index (WUSPI), Disabilities of Arm, Shoulder, and Hand (DASH) Index, and Shoulder Rating Questionnaire (SRQ). Secondary outcomes of strength were measured with isometric strength tests of scapulothoracic and glenohumeral muscles, and a static fatigue test of the lower trapezius. Results Pain was reduced and function improved after the intervention. There was a significant main effect for pain and function between the 3 time points based on the Friedman signed-ranked test, WUSPI (χ22 = 5.10, P = .014), DASH Index (χ22 = 5.41, P = .012), and SRQ (χ22 = 23.71, P ≤.001). Wilcoxon signed-rank tests demonstrated that isometric strength measurements of the serratus anterior and scapular retractors increased after the exercise intervention ([t = 2.42, P = .04] and [t = 4.67, P = .003], respectively). Muscle impulse produced by the lower trapezius during a fatigue task also improved (t = 2.2, P = .02). No differences were measured in isometric strength for the lower trapezius, glenohumeral rotators, and abductors between the baseline and 12-week time points. Conclusions A high-dose scapular stabilizer and rotator cuff strengthening program using telerehabilitation for supervision holds promise for shoulder pain treatment in manual wheelchair users with SCI. Additional work is needed to determine the effectiveness compared with other interventions, as well as the potential for earlier intervention to prevent development of shoulder pain.

A robust method for identifying movement in the free-living environment is needed to objectively measure physical activity. The purpose of this study was to validate the identification of postural orientation and movement from acceleration data against visual inspection from video recordings. Using tri-axial accelerometers placed on the waist and thigh, static orientations of standing, sitting, and lying down, as well as dynamic movements of walking, jogging and transitions between postures were identified. Additionally, subjects walked and jogged at self-selected slow, comfortable, and fast speeds. Identification of tasks was performed using a combination of the signal magnitude area, continuous wavelet transforms and accelerometer orientations. Twelve healthy adults were studied in the laboratory, with two investigators identifying tasks during each second of video observation. The intraclass correlation coefficients for inter-rater reliability were greater than 0.95 for all activities except for transitions. Results demonstrated high validity, with sensitivity and positive predictive values of greater than 85% for sitting and lying, with walking and jogging identified at greater than 90%. The greatest disagreement in identification accuracy between the algorithm and video occurred when subjects were asked to fidget while standing or sitting. During variable speed tasks, gait was correctly identified for speeds between 0.1m/s and 4.8m/s. This study included a range of walking speeds and natural movements such as fidgeting during static postures, demonstrating that accelerometer data can be used to identify orientation and movement among the general population.

A subject-specific step counting method with a high accuracy level at all walking speeds is needed to assess the functional level of impaired patients. The study aim was to validate step counts and cadence calculations from acceleration data by comparison to video data during dynamic activity. Custom-built activity monitors, each containing one tri-axial accelerometer, were placed on the ankles, thigh, and waist of 11 healthy adults. ICC values were greater than 0.98 for video inter-rater reliability of all step counts. The activity monitoring system (AMS) algorithm demonstrated a median (interquartile range; IQR) agreement of 92% (8%) with visual observations during walking/jogging trials at gait velocities ranging from 0.1 m/s to 4.8 m/s, while FitBits (ankle and waist), and a Nike Fuelband (wrist) demonstrated agreements of 92% (36%), 93% (22%), and 33% (35%), respectively. The algorithm results demonstrated high median (IQR) step detection sensitivity (95% (2%)), positive predictive value (PPV) (99% (1%)), and agreement (97% (3%)) during a laboratory-based simulated free-living protocol. The algorithm also showed high median (IQR) sensitivity, PPV, and agreement identifying walking steps (91% (5%), 98% (4%), and 96% (5%)), jogging steps (97% (6%), 100% (1%), and 95% (6%)), and less than 3% mean error in cadence calculations.

Two experiments extended and tested Deutsch's (1993) theory of competition effects. A knowledge structure approach predicted that people view competitive situations as inherently more aggressive than cooperative ones. Furthermore, it was predicted that leading people to think of an ambiguously aggressive situation in competitive terms would increase aggressive behavior. In Experiment 1, knowledge structures of competitive situations had more aggressive content than cooperative ones. In Experiment 2, competition-primed subjects unnecessarily killed more video game characters (Mario Brothers) than cooperation-primed subjects. The increase in kill ratio occurred in the absence of changes in hostility, friendliness, or liking for one's game partner. Implications for understanding cooperation and competition, and for further research on such "affectless agression," were discussed.

Patients with a mean postoperative blood glucose of >200 mg/dL or a preoperative hemoglobin A1C level of >6.7% are at increased risk for wound complications following elective primary total joint arthroplasty. These results show that poor preoperative and postoperative glucose control is independently associated with wound complications.

The purpose of this study was to validate a commercially available IMU system against a standard lab-based motion capture system for the measurement of shoulder elevation, elbow flexion, trunk flexion/extension and neck flexion/extension kinematics. The validation analyses were applied to six surgical faculty members performing a standard, simulated surgical training task that mimics minimally invasive surgery. Three-dimensional joint kinematics were simultaneously recorded by an optical motion capture system and an IMU system with six sensors placed on the head, chest, and bilateral upper and lower arms. The sensor-to-segment axes alignment was accomplished manually. The IMU neck and trunk IMU flexion/extension angles were accurate to within 2.9±0.9 degrees and 1.6±1.1 degrees, respectively. The IMU shoulder elevation measure was accurate to within 6.8±2.7 degrees and the elbow flexion measure was accurate to within 8.2±2.8 degrees. In the Bland-Altman analyses, there were no significant systematic errors present; however, there was a significant inversely proportional error across all joints. As the gold standard measurement increased, the IMU underestimated the magnitude of the joint angle. This study reports acceptable accuracy of a commercially available IMU system; however, results should be interpreted as protocol specific.

Objective-To evaluate upper-extremity symmetry during wheelchair propulsion across multiple terrain surfaces. Design-Case series.Setting-A biomechanics laboratory and the community. Participants-Manual wheelchair users (N=12). Interventions-Not applicable.Main Outcome Measures-Symmetry indexes for the propulsion moment, total force, tangential force, fractional effective force, time-to-peak propulsion moment, work, length of push cycle, and power during wheelchair propulsion over outdoor and indoor community conditions, and in conditions.Results-Upper-extremity asymmetry was present within each condition. There were no differences in the magnitude of asymmetry when comparing laboratory with indoor community conditions. Outdoor community wheelchair propulsion asymmetry was significantly greater than asymmetry measured during laboratory conditions. Conclusions-Investigators should be aware that manual wheelchair propulsion is an asymmetrical act, which may influence interpretation when data is collected from a single limb or averaged for both limbs. The greater asymmetry identified during outdoor versus laboratory conditions the emphasizes need to evaluate wheelchair biomechanics in the user's natural environment. KeywordsBiomechanics; Rehabilitation; Upper extremity; Wheelchairs THE BILATERAL NATURE of wheelchair propulsion places both upper extremities at risk for overuse injury. Upper-extremity pain 1-3 and overuse injury [4][5][6] are common in manual wheelchair users. Limb pain is frequently associated with activities of daily living 2,3,7 and is hypothesized to be a consequence of repetitive wheeling (eg, manually propelling a wheelchair) and upper-extremity weight bearing activities. The novel mode of ambulation © 2008 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation Reprint requests to Kai-Nan An, PhD, Guggenheim Bldg 1-28, Rochester, MN 55905, an.kainan@mayo.edu.. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. and potential deleterious impact on function has consequently made wheelchair propulsion the focus of many biomechanic investigations. NIH Public AccessMeasurement of propulsion force is now possible with instrumented wheelchair rims. The technology is, however, expensive. Often investigators are able to purchase only 1 instrumented rim, limiting studies to evaluation of 1 extremity. Investigators who have collected bilateral upper-extremity kinetic data during wheelchair propulsion subsequently averaged the data for both limbs [8][9][10] or have selected only 1 limb for analysis. 11 This suggests that side-to-side differences during wheelchair propulsion are not meaningful. However, in a study of pushrim propulsion patterns, Boninger et al 12 alanalyzed left and right upper extremities separately and reported that several subjects had different propulsion pa...

Background-Shoulder impingement syndrome is a common upper extremity pathology in manual wheelchair users. Central to impingement is the orientation of the scapula and humerus as they determine the available subacromial space. The purpose of this study was to examine the scapulothoracic and glenohumeral internal/external rotation kinematics during the time of peak shoulder loading of propulsion and weight relief lift conditions to assess possible risk of impingement.