An Overview of Neck Pain in Wheelchair Users
Top Contributors - Mark Sia and Kim Jackson
- 1 Introduction
- 2 Epidemiology
- 3 Prevalence of Neck Pain in Wheelchair Users
- 4 Neck Pain in Wheelchair Users
- 5 Aetiology and Risk Factors
- 6 Assessment Tools for Neck Pain in Wheelchair Users
- 7 Management
- 8 Strategies for Preserving Independent Mobility as Long as Possible
- 9 Conclusion
- 10 References
There are approximately 1.2million wheelchair users in the UK. However, within this large population, there are a variety of different types of wheelchair users, such as self propelled, assistant propelled and electric powered wheelchair users and the needs of all of them can be subtly different. Usage varies from daily use to competitive use. There are also those who are ambulatory wheelchair users - users who can at times mobilise without the need for a chair but use a chair for more effective, appropriate or pain-free ways of getting around.
Prevalence of Neck Pain in Wheelchair Users
General Pain in Wheelchair Users
A qualitative study interviewed 64 electric powered wheelchair users about their experiences of pain since becoming a wheelchair user:
- 86% of participants experienced pain related to sitting in past or present wheelchairs
- 59% felt their pain was influenced by their wheelchair
- 17% reported experiencing severe pain
Neck Pain in Wheelchair Users
A cross-sectional cohort study to evaluate neck pain of wheelchair users. This study used a convenience sample (n=68) of wheelchair users from the National Veteran’s Wheelchair Games. The aim of the study is to assess the significance of neck pain in wheelchair users and to establish if a portion of the neck pain may be myofascial in origin. A questionnaire and physical examination were used for this study. The inclusion was stated but exclusion criteria were not clearly defined in this study. There were no restrictions regarding the subject’s gender, race or physical/health status. This study provides an initial step in stating the prevalence and significance of neck pain with wheelchair users.
- 66% (n=45) reported neck/upper back pain at any time since they started using a wheelchair
- 54% (n=34) pain was reproduced by trigger-point palpation
A cross-sectional study conducted at 4 major Spanish hospitals offering education and training related to using a wheelchair permanently, either due to spinal cord injury or other reasons. This study has an adequate sample size (n=750), used a robust methodology and detailed inclusion/exclusion criteria. Aims of the study were to determine the prevalence of neck, thoracic and low back pain and to recognise the factors linked with pain among permanent wheelchair users. The pain was clearly defined as a 'mechanical' type of pain as opposed to neuropathic or inflammatory type pain (i.e. rheumatoid arthritis or ankylosing spondylitis). Additionally, the study identified that there is limited research pertaining to 'mechanical' spinal pain at all levels within wheelchair users as a population. The study focused on permanent wheelchair users and excluded the population who uses wheelchair transitorily or intermittently. This is identified as a limitation of this study as the results found may not apply for the population who uses wheelchair temporary (i.e. for fractures or post-surgery recovery).
- 56% = prevalence of neck pain
- 54% = prevalence of thoracic pain
- 45% = prevalence of low back pain
Kovacs et al., 2018
Both of these studies showed that the prevalence of neck pain is high with wheelchair users. Currently, there is not enough studies that explore neck pain with wheelchair users. Both studies suggested that appropriate longitudinal studies should be completed to investigate the cause of neck pain.
Aetiology and Risk Factors
There has been research into potential causes of neck pain in wheelchair users, with a lot of the research focusing on a broad area of 'wheelchair ergonomics' and associating the effects of positioning and posture in wheelchair users with neck pain. There has also been research into the effect of different terrains and neck pain and also another possible cause of neck pain in this population may be underlying conditions which may or may not have led to them becoming a wheelchair user. It is important that there is a strong consideration of the biopsychosocial model of health when it comes to wheelchair users who require a holistic approach to their management and understanding of the challenges being in a wheelchair exposes them to.
Posture and Positioning
Research has suggested that wheelchair users themselves sit in an increased amount of cervical flexion compared to non-wheelchair users. Also, periods of sustained cervical extension and rotation were reported to be most uncomfortable for wheelchair users. Considering the implications for wheelchair users of having to be functional from a seated position, in poorly adapted environments it is plausible to suggest they may be in cervical extension (and possibly rotation) for a sustained period of time which may then impact their neck pain.
This paper had a small sample size of 20 participants making it difficult to apply the results to the study population. This paper determined participants most comfortable positions by asking participants to find their most comfortable positions with their eyes closed. Participants were then asked to sustain a neutral position, extension, rotation (in a neutral position and extension) for 5 minutes. The order of each portion was random for each participant, however, it was not mentioned whether the degree of each movement was consistent between participants. ROM was determined from digital photographs. This paper does not mention whether assessors were blinded. The discomfort was measured using the visual analogue scale (VAS) in percentages. The average VAS score for extension was 24.0% and 34.1% for the extension with rotation. These results were statistically significant.
Wheelchair ergonomics relates to a wide variety of issues that ultimately may impact on the positioning of patients in a wheelchair. This may include seat heights, widths and depths, thoracic supports, lumbar supports, cervical supports, arm supports, cushions, angle of footrests or any other adaptations that may influence positioning and subsequently the neck posture and position in patients.
For example, a patient may have become a wheelchair user as a result of a neurodegenerative condition such as multiple sclerosis and as a result have a very impaired sitting balance due to a loss of muscle strength, endurance and co-ordination. As a result, they may require a variety of wheelchair supports in order to keep them in a comfortable position. All of these adaptations can influence the posture of the patient.
Seat height has an impact on the neck position during functional tasks. In a 2016 study, a lower seat height was shown to cause participants to go into greater cervical extension and shoulder abduction which was associated with repetitive overuse type injuries to shoulder complex and C-spine in wheelchair users.
As a result of this it is important that when a patient becomes a wheelchair user, they are referred to 'Wheelchair Services' and are assessed comprehensively in order to be provided with a wheelchair that is best suited to their needs and is an appropriate fit when it comes to factors such as seat depth, width, height and has the required supports where needed. If conditions or symptoms change or develop as a wheelchair user and there is a concern that the wheelchair no longer is adequate, again this should require a referral to wheelchair services for an assessment and alterations to the chair made as required.
Electric vs Self Propelled?
It has been suggested that those who use electric power wheelchairs could be less susceptible to developing neck pain than those who self-propel due to the increased physical demands from self-propelling and specifically the increased demands on the predominantly shoulder but also Cervical spine musculature required to self-propel. Kovacs et al also suggest that there is a decreased prevalence of any level spinal pain in those who use electric powered wheelchairs, although they do note that is only mildly less prevalent than in manual wheelchair users. In their study out of 603 manual wheelchair users, 299 reported mechanical neck pain (49.6%) and out of 147 electric power wheelchair users, 58 reported neck pain (39.5%). Clearly, there are differences relating to sample size in this comparison which makes conclusions difficult on this area. There is also further evidence that suggests that electric wheelchair users still suffer from neck pain  This suggests that there is more of a focus on wheelchair ergonomics and other factors than simply equating the increased demands of self-propelling to the increased prevalence of neck pain in wheelchair users.
In interviews with 64 wheelchair users, one common theme that was elicited was the potential impact that kerbs and differing terrains have on neck pain in this group. Uneven surfaces not only increase the physical demands on those self-propelling as more force is required to overcome the increased resistance but also the vibrations and 'jolting' that occurs with going over uneven surfaces has been associated with neck pain by wheelchair users themselves.
One interviewee responded "Sometimes I get more pain when I'm going up kerbs. Especially if I jolt or if there's a bumpy pavement and there's a lot of those and I just get a jolting through my back because there's no suspension on a wheelchair so it just travels straight up my back”.
The idea that challenging terrains may be problematic for wheelchair users is supported by NICE Guidance on the issue that suggests 'Local councils should improve the quality of footpaths so more people can be active'.
It is also important to consider the potential impact of underlying medical conditions and the contribution these can have on neck pain. These could be long term conditions such as Osteoarthritis or could be the conditions that have led to them becoming a wheelchair user such as a trauma (i.e. RTA that led to spinal cord damage).
Whilst it is difficult, mostly due to limitations in the small amount of research into the area, to suggest definitive causes of neck pain in wheelchair users, there is stronger evidence to suggest what may increase patients likelihood of developing neck pain after becoming a wheelchair user.
- Age - an increased age is associated with increased prevalence of neck pain in this population
- Duration of being a wheelchair user - the longer the patient has been a wheelchair user the more likely they are to develop neck pain
- Decreased Activity Levels - the majority of wheelchair users do not meet physical activity recommendations and is associated with secondary medical complications
- Decreased societal engagement - impact on psychological health and well-being and association in the pain perspective. Those with a decreased quality of life have an increased risk of developing neck pain in wheelchair users
- Living alone - the increased dependency as a result of living alone and having to be functional completely independent increases the physical demands on the individual thus increasing the risk of developing pain.
What are Wheelchair Users Exposed To?
- Whole body vibrations 
- Being functional from a seated position - having arms above shoulder height frequently 
- Enduring 'awkward' postures and positions
- Increased Risk of Pressure Sores 
It is important to have a consideration of all of the issues that wheelchair users may have to deal with. These 4 are only a small sample of the potential factors that someone living with a mobility issue may have to deal with. It is vital that any assessment of a wheelchair user, as with all patients, is truly holistic. For example if we consider the impact of decreased mobility leading to increased risk of pressure sores, there are the physical implications of skin breakdown and pain, then there is the societal and psychological impact that to resolve the pressure sore will potentially require decreased social interaction as the patient is unable to use their chair as much potentially.
Assessment Tools for Neck Pain in Wheelchair Users
There are a variety of generic subjective assessment tools that can be used to help assess neck pain in wheelchair users. These may focus on pain, disability or more psychosocial factors such as depression. For example, the following tools could be used:
- Visual Analogue Scale (VAS)
- Neck Disability Index
- Quality Life Index
- Depression Scores such as CEDS
However, there is one tool that has a much greater specificity to this population, the Wheelchair Seating Discomfort Assessment Tool. Research into this tool has shown it to be highly reliable with strong validity. The tool assesses details pertaining to disability and secondary conditions and timescales of these, weight and height, seating arrangement and equipment in place on the chair, functional level and then the level of discomfort with a range of questions on these issues. A tool like this should be used in the comprehensive assessment required by wheelchair users to ensure wheelchairs are suitable.
Mechanical neck pain has a variety of potential treatment modalities and methods. Whilst there is some evidence into specifically wheelchair users with neck pain, more research would be beneficial. However, it can be expected that the management of mechanical neck pain in the general population will have a large overlap with the management for this specific population. Overall management can be divided into four main areas:
- Complementary Therapy (i.e. manual therapies)
Education is a vital role in the management of patients with neck pain and should involve reinforcing positive messages about remaining active, providing information about the injury and recovery, addressing negative beliefs and ideas and potentially discussing pain education . Further information around the issue of education for general neck pain can be found here. Evidence Based Interventions for Neck Pain
Analgesia is predominantly one of the first and most frequently used form of management for neck pain. A recent study  showed that this is also the case in this specific population. Although the nature of the analgesia was not specified, taking muscle relaxants and anti-spasticity medications were mentioned by some users. A study in Australia showed for patients with neck pain, GPs used paracetamol more than opioid medications.
Exercise therapy is a very broad area and there is evidence specifically into wheelchair user groups as well as more generic evidence for its management. Focusing specifically on wheelchair users, work on sitting balance and trunk strength and endurance may be beneficial, as will functional seated exercises. Ultimately an individualised approach will be required. More generic neck strengthening, endurance and flexibility exercises will be beneficial depending on what deficits are noted on observation. Furthermore, there is research into more general activities such as Tai Chi and Pilates group sessions for wheelchair users that shows beneficial results in terms of function and pain but also in improving quality of life, an important consideration in this population.
Sitting Balance and Functional Seated Exercise
More specifically to wheelchair users, sitting balance and functional seated exercise would be more specific in aiding patients function and decreasing their pain as they become more active and are able to control positioning and posture more independently.
A 2019 literature review investigated the effect of seated exercises for older adults. It found that seated exercises had a large positive impact on cognition. Additionally, it found that seated exercises improved strength and spinal flexion. Furthermore, there were improvements of level of activity and quality of life. However, it found limited evidence on the impacts of balance and mobility
This literature review excluded articles that involved exercises that were not seated or used equipment such as exercises bikes. It focussed on articles that only looked at patient outcomes, not carer outcomes. The paper initially found 2640 papers and reduced to 14 articles independently by two reviewers with disagreement involving a third reviewer. Methodological quality of the included trials was assessed using the PEDro scale. Nine of the fourteen trails scored high quality.
A systematic review involving 11 studies (317 participants) investigated the impact trunk training had on sitting balance. It found evidence that trunk training exercises improved dynamic sitting balance.
This literature review looked at the effects trunk training had on stroke patients which is different to the population this article is looking at, however, it does observe the effects on sitting balance. This paper only involved RCTs and had an exclusion criteria for participants. Its primary outcome measure whethe re level of trunk performance (using the Trunk Impairment Scale (TIS)) and functional sitting balance (using TIS sub scales). Its initial search found 1761 papers before being reduced to 11 independently by two reviewers. The authors used the PEDro scale to assess the quality of methodology.
General Neck ROM, Strength and Endurance Exercises
Specific moderate to high-intensity neck muscle training can lower neck pain. Regular intensive exercises will increase muscle range of motion and power leading to enriched function and less disability in people with chronic neck pain. It is recommended to do the neck exercises for a few months but displayed to produce only temporary improvements. Therefore, it is recommended to do long-term progressive resistance training for neck and shoulder muscles. Finally, these types of training can be independently be executed at home with a low-cost training kit.
Evidence surrounding exercises suggest that this must be part of the treatment package provided for a patient with any case of neck pain.
Group General Activity
A 2014 study looked at using a 12-week group Pilates programme for wheelchair users who were suffering from MS. 15 participants underwent the programme who had to be 18 or over and able to use a wheelchair and transfer independently or with the assistance of 1 or a slide board to aid the transfer. The programme involved a lot of core stability and endurance exercises designed to improve sitting balance. After 12 weeks, there were significant improvements in breathing, sitting posture, shoulder, neck and back pain assessed via VAS and significant improvements in function too. Although this study focused on a small sample of MS patients it shows that wheelchair users who undertake a group activity that has a targeted aim (in this case improving core function and sitting balance) will receive multiple biopsychosocial health benefits.
Tai Chi and Balance
An RCT involving 40 participants investigated the effect tai chi had on balance and quality of life. Participants were assigned to the wheelchair tai chi (WCTC) group or a control group. The WCTC intervention involved two 30 minute sessions a day for 5 days a week over a 6 weeks period. The control group just continued with their normal treatment. The study found that there was a significant difference in balance control time between the two groups after the intervention. Additionally, the study found a significant improvement in the quality of life. Improving sitting balance may help wheelchair users to maintain a posture that is comfortable to them. Furthermore, tai chi can improve quality of life for wheelchair users and provides a holistic approach to care.
This paper had a small sample size of 40 participants. The inclusion criteria were people who were diagnosed with spinal cord injury, according to the American Spinal Injury Association’s criteria for diagnosis, aged between 20 and 70 years old, able to communicate and follow instructions and able to maintain a sitting posture for more than 30 mins. Because this study looked at SCIs it didn’t match the study population of this page. However, it’s findings could still be applied to other wheelchair users. The exclusion criteria were people with an unstable spine, cancer, serious cardiopulmonary diseases, poorly managed hypertension, poorly managed hypertonia or other serious complications such as pressure ulcers. The assessors and tai chi instructor were blinded to the study. The study was aware of its limitations. A future study may be needed to assess the long term effects of tai chi as this paper did not complete follow up assessments.
Complementary Therapies (Manual Therapy)
Evidence surrounding the effectiveness of manual therapy for neck pain with wheelchair users is limited. However, manual therapy is a modality in the treatment of mechanical neck pain in the general population. Therefore, it may contribute to its relevance in this specific population.
An RCT with sixty-four such patients were randomized to receive up to 10 massages over 10 weeks or a self-care book. The results showed that therapeutic massage has short term clinical benefits for people with neck pain. Additionally, the study suggests that therapeutic massage is safe, however, a larger trial is needed to ratify these results.
A Cochrane review presented that multiple sessions of cervical manipulation may provide better pain relief and improvement in function than medications at immediate/intermediate/long-term follow-up. However, there is less effectiveness for manipulation in longer-term or chronic presentations of neck pain. Limited high-quality evidence was found so ambiguity is likely to have an impact on the effectiveness of manipulation. 
In summary, current evidence shows that manual therapy presents its value for the short-term management of mechanical neck pain only. Long-term manual therapy management does not have strong evidence-based effectiveness. Future research is likely to have a significant impact on the effectiveness of these treatments.
Strategies for Preserving Independent Mobility as Long as Possible
Requejo et al  have identified a wide range of strategies for preserving wheelchair users ability to self-propel and self-mobilise independently for as long as possible. As discussed in the paper by maintaining independent mobility the subsequent improvements to psychological health, maintaining confidence and self-esteem and improving quality of life are significant alongside the general physical health that maintaining active and engaging in physical activity has in reducing secondary complications such as pressure ulcers, obesity, diabetes, osteoporosis, and cardiovascular co-morbidities. All of these contribute to the increased risk factors discussed earlier on this page. The strategies include:
- Minimise forces required to complete tasks (i.e. providing sliding boards to assist transfers)
- Minimise frequency of repetitive upper limb tasks
- Minimise extreme or potentially injurious positions
- Lighter, adjustable wheelchairs
- Good Wheelchair ergonomics
- Flexibility and Resistance Exercise Training Programme
- Promote good posture and support it depending on balance requirements
Overall, 'mechanical' type neck pain is very common in patients who have become wheelchair users. Whilst there is overlap with general mechanical neck pain there are some important key differences in its cases. Wheelchair ergonomics plays a large role in posture and positioning of patients in wheelchairs and therefore comprehensive assessments are required for appropriate wheelchair fittings. Being in a wheelchair can have a large impact on biopsychosocial health and it is important to treat patients holistically. There is limited research into the management of neck pain in wheelchair users, however, it can be treated using a standard multi-factorial treatment plan incorporating education, exercise, medication and for short term benefits only, manual therapies. However, what has been apparent throughout the research and design process of this page is the need for far greater research into wheelchair users as a population in general.
- NHS England. (2014). Improving Wheelchair Services. Available: https://www.england.nhs.uk/wheelchair-services/. Last accessed 22nd May 2019.
- Frank, A. De Souza, L. Frank, J. Neophytou, C. (2012). The pain experiences of powered wheelchair users. Disability and Rehabilitation . 34 (9), 770-778.
- Boninger, M.L., Cooper, R.A., Fitzgerald, S.G., Lin, J., Cooper, R., Dicianno, B. and Liu, B., 2003. Investigating neck pain in wheelchair users. American journal of physical medicine & rehabilitation, 82(3), pp.197-202
- Kovacs, F.M., Seco, J., Royuela, A., Barriga, A. and Zamora, J., 2018. Prevalence and factors associated with a higher risk of neck and back pain among permanent wheelchair users: a cross-sectional study. Spinal cord, 56(4), p.392.
- Kirby, R. L., Fahie, C. L., Smith, C., Chester, E. L., & Macleod, D. A. (2004). Neck discomfort of wheelchair users: Effect of neck position. Disability & Rehabilitation, 26(1), 9–15.
- Sabari, J. Shea, M. Chen, L. Laurenceau, A. Leung, E. (2016). Impact of wheelchair seat height on neck and shoulder range of motion during functional task performance. Assistive Technology. 20 (3), 183-189.
- K.A. Curtis, G.A. Drysdale, R.D. Lanza, M. Kolber, R.S. Vitolo, R. West, 1999, Shoulder pain in wheelchair users with tetraplegia and paraplegia, Arch. Phys Med Rehabil, 80 (4) 453-457
- Gibson J, Frank A, 2005, The Pain experienced by electric powered wheelchair users: a pilot exploration using pain drawings Physiotherapy Research International, 10, 110-115
- NICE. (2018). Local councils should improve the quality of footpaths so more people can be active. Available: https://www.nice.org.uk/news/article/local-councils-should-improve-the-quality-of-footpaths-so-more-people-can-be-active-says-nice. Last accessed 23rd May 2018.
- Requejo PS, Furumaso J, Mulroy SJ, 2016, Evidence-Based Strategies for Preserving Mobility for Elderly and Aging Manual Wheelchair Users, Geriatric Rehabilitation, 31, 26-41
- Finley MA, Euiler E, 2019, Association of musculoskeletal pain, fear-avoidance factors, and quality of life in active manual wheelchair users with SCI: A pilot study, Journal of Spinal Cord Medicine, 42, 225-229
- Hastings, J., Robins, H., Griffiths, Y., & Hamilton, C. (2011). The differ- ences in self-esteem, function, and participation between adults with low cervical motor tetraplegia who use power or manual wheelchairs.Archives of Physical Medicine and Rehabilitation, 92(11), 1785–1788.
- Farley, R. Clark, J. Davidson, C. Evans, G. MacLennan, K. Michael, S. Morrow, M. Thorpe, S.. (2003). What is the evidence for the effectiveness of postural management?. International Journal of Therapeutics and Rehabilitation. 10 (10), 449-455.
- Moore ZEH, van Etten MT, Dumville JC. Bed rest for pressure ulcer healing in wheelchair users. Cochrane Database of Systematic Reviews 2016, Issue 10. Art. No.: CD011999
- Crane BA, Holm MB, Hobson D, Cooper RA, Reed MP, Stadelmier S, 2005, Test-Retest Reliability, Internal Item consistency, and concurrent validity of the wheelchair seating discomfort assessment tool, Journal of Assistive Technology, 17, 98-107
- Bedell SE, Graboys TB, Bedell E, Lown B. Words that harm, words that heal. Arch Intern Med 2004; 164:1365–8
- Rebbeck T. The Role of Exercise and Patient Education in the Noninvasive Management of Whiplash: A Clinical Commentary. Journal of Orthopaedic & Sports Physical Therapy. 2017 Jun 16(0):1-32
- Sexton, B. P. and Taylor, N. F. (2019), To sit or not to sit? A systematic review and meta‐analysis of seated exercise for older adults. Australas J Ageing, 38: 15-27
- Cabanas, R. Bagur-Calafat, MC.. (2013). Trunk training exercises approaches for improving trunk performance and functional sitting balance in patients with stroke: A systematic review. NeuroRehabilitation. 33 (1), 575-592
- Ylinen, J., 2007. Physical exercises and functional rehabilitation for the management of chronic neck pain. Europa medicophysica, 43(1), p.119.
- van der Linden, M.L., Bulley, C., Geneen, L.J., Hooper, J.E., Cowan, P. and Mercer, T.H., 2014. Pilates for people with multiple sclerosis who use a wheelchair: feasibility, efficacy and participant experiences. Disability and rehabilitation, 36(11), pp.932-939.
- Qi, Y. Zhang, X. Zhoa, Y. Xie, H. Shen, Y. Niu, W. Wang, Y. (2018). The effect of wheelchair Tai Chi on balance control and quality of life among survivors of spinal cord injuries: A randomized controlled trial. Complementary Therapies in Clinical Practice. 33 (1), 7-11.
- Patel, K.C., Gross, A., Graham, N., Goldsmith, C.H., Ezzo, J., Morien, A. and Peloso, P.M.J., 2012. Massage for mechanical neck disorders. Cochrane Database of Systematic Reviews, (9).
- Gross, A., Hoving, J.L., Haines, T., Goldsmith, C.H., Kay, T.M., Aker, P., Brønfort, G. and Cervical Overview Group, 2004. Manipulation and mobilisation for mechanical neck disorders. Cochrane Database of Systematic Reviews, (1).