Over 50 percent of manual wheelchair users with spinal cord injury (SCI) are likely to develop upper-limb pain and injury. The majority of studies related to pain have implicated wheelchair propulsion as a cause. This paper draws from a large multisite trial and a long-standing research program to make specific recommendations related to wheelchair propulsion that may decrease the risk of upper-limb injury. The studies include over 60 subjects over 1 yr after a traumatic SCI below the second thoracic level. Specific aspects of the propulsive stroke that may relate to injury include cadence, magnitude of force, and the pattern of the hand during the nonpropulsive part of the stroke. Lower peak forces, slower cadence, and a circular propulsive stroke in which the hand falls below the pushrim during recovery may help prevent injury. In addition, wheelchair users should use the lightest weight adjustable wheelchair possible. Future work should include interventional trials and larger studies that allow for more complex statistical models that can further detail the relationship between wheelchair propulsion, user characteristics, and upper-limb injuries.

The interaction among symptoms, physical examination, and nerve conduction study findings is complex. Carpal tunnel syndrome and median mononeuropathy are highly prevalent and functionally significant. This study highlights the need for primary prevention and patient education for preserving upper-limb function.