Bimanual wheelchair propulsion by people with severe hemiparesis after stroke

Abstract

250 word max) Aim: Individuals who require manual wheelchairs after stroke are typically taught to ambulate with compensatory propulsion (i.e. using their nonparetic arm and foot), risking disuse of the paretic arm. We investigated whether stroke survivors can instead ambulate in a bimanual, leverdriven wheelchair that requires the paretic arm to contribute half the propulsive input.Methods: Seventeen individuals with chronic stroke and severe hemiparesis (upper extremity Fugl-Meyer scores between 10 and 24) participated across two experiments. In the first experiment participants (n=12) ambulated in straight paths. In the second experiment participants (n=12) also performed turns, using an improved version of the wheelchair that incorporated handbrakes.Twelve unimpaired controls also completed the second experiment. Motion capture and EMG were used to compare biomechanics between groups.Results: Altogether, 15 of 17 participants with stroke could ambulate 30 m in straight paths, and 9 of 12 could turn 1800° entirely under the power of their paretic arm. Participants with stroke exhibited largely healthy biomechanics, with minimal shoulder hiking/leaning or trunk inclination.Their arm muscle EMG patterns were similar to those used by unimpaired participants, excepting delayed elbow extensor activation.Conclusions: Individuals with severe arm impairment in the chronic stage of stroke retain sufficient strength and coordination with their paretic arm to maneuver bimanual, lever-driven wheelchairs. We suggest bimanual, lever driven propulsion should be explored in stroke rehabilitation practice as an alternative to compensatory wheelchair propulsion, as it has the potential to exercise healthy movement synergies, which may in turn help drive use-dependent motor recovery.

A Dynamic Wheelchair Armrest for Promoting Arm Exercise and Mobility After Stroke

“…The device described here takes into account our experience developing and testing lever-drive wheelchairs for stroke rehabilitation [17]- [19]. We found that individuals with severe arm impairment in the chronic stage of stroke retain sufficient strength and coordination with their paretic arm to manoeuvre bimanual, lever-driven wheelchairs [17], [18]. Participants with stroke exhibited largely healthy biomechanics, with minimal shoulder hiking/leaning or trunk inclination.…”

“…We modified this initial lever drive chair design with a hand clutching design to allow turning in place and backing up [17]. In a randomized control trial, we found that exercise with this device in the subacute phase of stroke led to a reduction in arm impairment compared to conventional treatment, demonstrating the therapeutic potential of wheelchair-based arm exercise after stroke [18]. However, therapists noted that the hand clutching technique required for overground propulsion placed a high cognitive demand on patients, and most struggled to learn to use the device for propulsion.…”

Using a bimanual lever-driven wheelchair for arm movement practice early after stroke: A pilot, randomized, controlled, single-blind trial

“…Wheelchairs propelled with levers used by both arms have the potential to offer both mobility and arm exercise. 8,9 Such devices could lead to a paradigm shift in wheelchair use in stroke rehabilitation. Currently, wheelchairs are used for ambulation after stroke, but are not typically thought of as a tool for exercise of the hemiparetic arm.…”

“…LARA (Lever-Actuated Rehabilitation and Ambulation) is a bimanual lever-driven wheelchair configured so that the paretic arm contributes to propulsion. 8,13 Pilot testing with a precursor device called RAE (the Resonating Arm Exerciser), which utilized the same lever configuration as LARA, showed that individuals with severe arm impairment in the chronic stage of stroke can pump a lever attached to the wheels of a wheelchair with their hemiparetic arm, rolling forward and backward, and that repeated pumping of these levers leads to therapeutic benefit. 14 We tested RAE in a home-based randomized control trial where independent training with RAE (~500 repetitions per hour) was found to be feasible and to significantly reduce arm impairment in individuals with chronic stroke, without increasing pain or tone.…”

“…16 We found that people with severe arm impairment from chronic stroke were able to reliably propel themselves overground, using the mechanically passive assistance of LARA, mostly without using abnormal compensatory shoulder or trunk movements. 8 We then implemented a novel drive system we call “yoked hand clutching” 13 and found that people with severe hemiparesis from chronic stroke could learn, over the course of several training sessions, to coordinate the levers and hand clutch to move forward, turn, and back-up. 9 The question remained whether persons early after a stroke could similarly learn to drive LARA using yoked hand clutching in a subacute rehabilitation setting, and whether such use would have a therapeutic effect on arm impairment.…”