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 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

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 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.

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.

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.

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.

Differing Terrains?

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'. ​

Underlying conditions?

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).

Increased Risk Factors and Biopsychosocial Considerations

Whilst it is difficult, mostly due to limitations in the small amount of research in to 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.

These include:

- Age - an increased age is associated with increased prevalence of neck pain in this population

- Duration of 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.

Management​

Tai Chi and balance

A 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.

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.