An Overview of Neck Pain in Wheelchair Users

This page will be discussing Neck Pain (acute, sub-acute or chronic) that has developed since becoming a wheelchair user, discussing the prevalence, aetiology and management of this area in this specific population. Neck pain is a very broad complaint and can have a wide variety of causes, however this page will focus on musculoskeletal type neck pain, which is common in wheelchair users.

Wheelchair Users as a population

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.

'Mechanical' Neck Pain

Mechanical neck pain lacks an identifiable pathoanatomic cause. For more information see mechanical neck pain.

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 study with 68 participants recruited from the National Veteran's Wheelchair Games​:

• 66% (n=45) reported neck/upper back pain at any time since they started using a wheelchair

A cross-sectional study with 750 participants 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. ​

• 56% reported neck pain

What is shown from these two studies, is that a 'mechanical' musculoskeletal type neck pain is a common condition affecting those in wheelchair users. Specifically, the Kovacs et al research used a robust inclusion/exclusion criteria meaning that only those with a 'mechanical' type pain as opposed to neuropathic or inflammatory type pain (that may be present in cases of rheumatoid arthritis or ankylosing spondylitis) were included and still showed a 56% prevalence of neck pain in a large sample size. Having said this, Kovacs also identifies that there is limited research pertaining to 'mechanical' spinal pain at all levels within wheelchair users as a population.

Aetiology and Risk Factors

There has been research in to 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 in to 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.

Wheelchair ergonomics

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 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 neuro-degenerative 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 function. In a 2016 study, a lower seat height was shown to cause participants to go in to 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 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.

A study involving 20 wheelchair users discovered that the most comfortable position for most of the participants was with their necks in 11º to 27º more flexion than an average-height sitting or standing person. This paper also discovered that sustained extension and rotation (either alone or combined), increased neck discomfort in wheelchair users. This emphasises the importance of appropriate wheelchair ergonomics to reduce the amount of time wheelchair users need to spend in sustained extension or rotation.

Critical Appraisal

(Frank et al, 2014) - This Paper included users who had been wheelchair users for 10 years before the interviews. However, it only interviewed wheelchair users who used Electric Powered Indoor/Outdoor Chairs (EPIOC) making it difficult to apply to other varieties of wheelchairs. Additionally, interviews were done over telephone eliminating the use of non-verbal communication making difficult to gain information from some participants who had communication difficulties. Furthermore, diagnostic data about participants was provided by the participants and not professional referrals. However, the authors stated that the participants were given appropriate diagnostic information by healthcare professionals. Lastly, this paper was aware of its limitations and provided a good analysis of qualitative data.

(Boninger et al, 2003) - Crit App: Limited Sample size, not enough literature looking at neck pain with wheelchair users, included no inclusion or exclusion criteria

(Kovacs et al, 2018) - Inclusion criteria, age >18 and permanent wheelchair user for more than >1 year​. Exclusion criteria sitting in a wheelchair intermittently or temporarily, suffering from physical or mental inability, which made it impossible to respond to the interviewer’s questions (e.g., pentaplegia or senile dementia), reporting being unable to distinguish neuropathic from mechanical pain, presenting fever, and having been diagnosed (or being in the diagnostic process) of cancer, systemic infection, or any inflammatory diseases such as spondylitis or rheumatoid arthritis.​ Crit appraisal: strong robust methology, well defined exclusion and inclusion criteria

(Sabari et al, 2016) - This observation study had an inclusion criteria. Participants needed to have no self-reported pain in the neck, spine, or right shoulder and they needed to have appropriate vision to accurately see images for the vision task. Participants completed both tasks in a powered wheelchair with the seat positioned in the minimum height and then maximum height. The first functional task involved participants had to determine whether images and a describing word matched. For example, a picture of flowers were displayed with the word tulips. The images were on a computer screen on a cabinet. The wheelchair was positioned in the same place for each participant to maintain consistency. The second task was a reaching task where the wheelchair was placed 19.5 inches from a with with participants had to reach and press. Measuring ROM could be improved as the investigators used a goniometer which has reduced inter-tester reliability. This paper used the same tester to take measurements. However, this assessor was not blinded to the study increasing the risk of bias. The results of this study found a statistically significant difference in cervical AROM between minimum and maximum seat height when performing task 1.

(Kirby et al, 2004) - 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 neural 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. Discomfort was measured using the visual analogue scale (VAS) in percentages. The average VAS score for extension was 24.0% and 34.1% for extension with rotation. These results were statistically significant.