| | Kinematic and Electromyographic Analysis of Wheelchair Propulsion on Ramps of Different Slopes for Young Men With ParaplegiaPresented to the American Society of Biomechanics, October 21-23, 1999, Pittsburgh, PA; the Congress of the International Society of Biomechanics, August 8-13, 1999, Calgary, Canada; and the American College of Sports Medicine, May 31-June 3, 2000, Indianapolis, IN. Abstract Chow JW, Millikan TA, Carlton LG, Chae W, Lim Y, Morse MI. Kinematic and electromyographic analysis of wheelchair propulsion on ramps of different slopes for young men with paraplegia. ObjectiveTo gain insight into the biomechanics of upslope wheelchair stroking by examining the changes in kinematic and electromyographic characteristics of wheelchair propulsion over ramps of different slopes. DesignRepeated-measures design. Each subject pushed up a wooden ramp (7.3m long) 3 times at self-selected normal and fast speeds for each of these slopes: 0°, 2°, 4°, 6°, 8°, 10°, and 12°. SettingA biomechanics laboratory. ParticipantsYoung men (N=10) with paraplegia. InterventionsNot applicable. Main Outcome MeasuresElectromyographic activity of extensor carpi radialis, triceps brachii, antero-middle and postero-middle deltoids, pectoralis major, and latissimus dorsi, and stroking kinematics. ResultsForward lean of the trunk increased as the slope increased. The triceps brachii, antero-middle deltoid, and pectoralis major were more active during the push phase, while the postero-middle deltoid was more active during the recovery phase. Both extensor carpi radialis and latissimus dorsi were active throughout a stroke. Major adjustments in stroking kinematics and significant increases in muscle activity occurred at slopes between 4° and 10°. ConclusionIn addition to a decrease in stroking speed, the stroking pattern becomes more compact (decreased push angle and relative recovery time, increased stroke frequency) and the trunk becomes more active with increasing slope. RAMPS ARE IMPORTANT because they provide the opportunity for people with locomotor disorders, especially wheelchair users, to overcome differences in grade levels. According to the ADAAG,1 a ramp is a walking surface that has a running slope greater than 1:20 (2.9°; ie, 2.54 cm [1in] of rise for every 50.8 cm [20in] of run). The ADAAG permits a maximum run (ramp length) of 40ft (12.2m) for slopes between 1:16 (3.6°) and 1:20. However, these guidelines do not apply to all buildings. Public buildings built before 1992 and privately built residential buildings are excluded. Therefore, a great variety of ramp slopes may be encountered by wheelchair users in everyday activities. This necessitates the need to study the demands imposed on the body by various ramp angles. A review of literature indicates that a number of studies have been conducted to evaluate propulsion abilities of wheelchair users.2, 3, 4, 5, 6, 7 Typically, subjects were asked to traverse ramps of different slopes and rated the degree of difficulty. Previous studies on biomechanics of wheelchair propulsion up a ramp have focused on upper-extremity joint kinetics, and few kinematic characteristics were reported.8, 9 Other studies have used motorized treadmills at various slopes10, 11, 12 or applied different resistances to a wheelchair ergometer/dynamometer to simulate level and inclined conditions.13, 14 Testing subjects on a treadmill using 4 slopes (0°–3°) and 4 speeds (0.55–1.39m/s), van der Woude et al11 reported that, at a given speed, the stroke and recovery times decreased and the push time and push angle remained constant with increasing slope based on qualitative analyses. With subjects pushing at self-selected speeds on a treadmill set at level, 3°, and 6° grades, Richter et al10 reported decreases in speed, push angle, and push frequency with increasing grade. Conversely, Kulig et al14 found a significant decrease in stroking speed, no significant change in stroke time (hence no change in push frequency), and a significant increase in push time from level to a simulated 8% incline condition. Treadmill and ergometer testing has limitations because it may not simulate overground wheeling accurately. Several studies have documented the muscle activation patterns during wheelchair propulsion using surface EMG techniques.13, 15, 16, 17, 18, 19 In general, anterior deltoid, biceps brachii, triceps brachii, flexor carpi radialis, extensor carpi radialis, and pectoralis major were reported to be active during the push phase, while middle and posterior deltoid muscles were identified as the prime movers during the recovery phase. Cerquiglini et al13 found the latissimus dorsi to be most active during the final phase of pushing, and the activity increased drastically when the resistance of the wheelchair ergometer was increased to simulate a 2% to 3% incline ramp. Mulroy et al20 found the anterior deltoid, sternal portion of pectoralis major, supraspinatus, infraspinatus, serratus anterior, and long head of biceps brachii to be active during the push phase. The recovery phase muscles were middle and posterior deltoid, subscapularis, supraspinatus, and middle trapezius. They did not observe any consistent pattern of activity in the latissimus dorsi. It is worth noting that most EMG studies on wheelchair propulsion to date have been conducted on either a roller system or a stationary ergometer. Both of these situations alter the factors of balance and coordination as occurs under natural everyday pushing activities. Furthermore, subjects in most of these studies did not use their own wheelchairs when they were tested. Upper-extremity pain and disorders are common among full time wheelchair users.21, 22, 23, 24 Kinetic analyses of upper-extremity joints during upslope propulsion provide some indication of the mechanical loads at different joints. However, EMG and kinematic analyses could provide further insights into muscle function and propulsion techniques that may help to minimize the demand placed on the upper extremities of wheelchair users while propelling up a ramp. To our knowledge, there has not been any study systematically examining the effect of incline angle on the kinematic and muscle activation characteristics of overground upslope wheelchair stroking. Thus, it was the purpose of this study to examine the changes in kinematic characteristics and activation patterns of selected muscles during wheelchair propulsion from level stroking to upslope stroking. The initial hypothesis was that slope would cause increases in muscle activation and push time; decreases in stroking speed, push angle, and recovery times; and no change in stroke time and stroke frequency.10, 14 Methods  Subjects Ten male full time wheelchair users ranging in age from 18 to 33 years (mean ± SD age, 22.3±5.3y; mass, 62±11kg) of different functional levels (5 paraplegia [T6–L3], 2 spina bifida [L2 and L5], 1 polio [L4], 1 osteogenesis imperfecta, 1 bilateral below-the-knee amputee) served as the subjects. The subjects in this convenience sample were all active in wheelchair sports and had no history of persistent joint disorder or musculoskeletal trauma in their upper extremities when the data were collected. The inclusion criteria were that the subjects be full time wheelchair users capable of pushing up a short ramp of 12° slope. All subjects signed informed consent documents approved by the institutional review board. Data Collection Ramp A wooden ramp of adjustable slopes—0° to 12° at intervals of 2°—was constructed (fig 1). The slopes were verified using a Pro Smartlevela measuring device. The adjustable end of the ramp was located underneath a balcony where pulley systems were installed. The ramp was 7.3m long and 1.1m wide. The ramp led to a 1.2m×1.2m platform. Video recording To obtain the right-hand side sagittal views of the stroking motion, a Panasonic AG455 S-VHS video camerab (60Hz field rate) was placed on a tripod, and the optical axis of the camera was parallel to the ground and perpendicular to the plane of action. The camera was approximately 25m from the ramp and 1.5m above the ground. The width of the optical field was approximately 3.5m at the plane of action. With the help of 2 floodlights, a fast shutter speed of .002 second was selected. No markers were placed on subjects' bodies. However, to facilitate manual digitizing, they wore no clothing above the waist. Electromyography recordings Six pairs of Liberty Technology MYO115 surface electrodesc with onsite preamplification circuitry (center-to-center distance=1.5cm, gain=1000, input impedance>1014 Ω, Common Mode Rejection Ratio>90dB, frequency response=bandpass 3dB at 90 and 500) were attached to the right side of the body: extensor carpi radialis, triceps brachii, antero-middle and postero-middle deltoids, pectoralis major, and latissimus dorsi muscles.25, 26, 27 The ground electrode was placed on the subject's right acromion. To obtain maximum EMG levels of the selected muscles for normalization, maximum effort isometric contractions were performed for each muscle before the experimental trials.26, 27 The EMG signals collected were further magnified using a general purpose amplifierd (model 215, input impedance=109 Ω, Common Mode Rejection Ratio>100dB, nonlinearity<.01%) before being digitized (12-bit) at a sampling rate of 1000Hz. Trials Using his own wheelchair, each subject was asked to perform a total of 6 trials of stroking for each slope condition—3 at a self-selected normal speed and 3 at a self-selected fast speed, a total of 42 trials (7 slopes × 2 speeds × 3 trials) for each subject. Slope conditions were presented randomly. In each trial, the subject pushed the whole length of the ramp and was videotaped. The EMG signals were collected for 5 seconds during the middle of the trial duration. To synchronize the video and EMG data, a synchronization unite was manually activated during sampling. The unit activated a large light-emitted diode, which was visible in the camera view, and forwarded a 3-V signal to the analog-to-digital converter of the EMG data collection system. An experimenter pulled a wagon holding the amplifier behind the subject in each trial. This did not hinder the subjects' movement because the electrode cables were of sufficient length (4m). The amplifier was connected to the EMG data collection system. Data Reduction The stroke when the subject's wheel passed the midpoint of the ramp was selected from each trial for analysis. For the purpose of this study, a stroke cycle starts at the instant of hand contact and ends at the instant immediately before the next hand contact. The instant the hand losses contact with the rim (hand release) divides a stroke cycle into 2 phases: the push and recovery phases (fig 2). For each subject, the average profile over 3 strokes (1 from each trial) was used in subsequent analysis. Video recordings For the selected strokes, coordinate data of 3 body landmarks (supra-sternal notch, right third knuckle of the middle finger, and right hip) and the right wheel center were manually extracted from the video images using a Peak Motion Measurement System.e For each trial analyzed, the digitizing started 10 fields before the first hand contact and ended 10 fields after the second hand contact, and the video field numbers of 3 critical instants were identified: (1) first initial hand contact, (2) hand release, and (3) second initial hand contact. Temporal parameters (stroke time, push, and recovery times expressed as a percentage of the stroke time, and stroke frequency) were determined using these field numbers and the time interval between consecutive fields (1/60s). The distance traveled in each stroke (stroke distance) was computed as the distance between the locations of the wheel center at the beginning and end of a stroke. The stroke speed was obtained by dividing the stroke distance by the stroke time. Regardless of slope, the locations of the hand relative to the top dead center (the highest point in an absolute global sense) at the instants of hand contact and hand release were represented by the contact and release angles, respectively (see fig 2). Because the hand was always located behind the top dead center of the wheel at hand contact, the contact angles were always negative in value. The push angle of a stroke was computed as the sum of the magnitudes of the contact and release angles (see fig 2). The inclinations and angular velocities of the trunk at the instants of hand contact and hand release were determined using the coordinates of the supra-sternal notch and hip. The trunk inclination is the angle between the trunk and the horizontal plane regardless of the ramp slope. The trunk angular velocity is positive if the trunk is rotating forward (trunk flexion). Electromyography recordings The raw EMG signals were filtered using a recursive digital filterf (10–500Hz band pass) and full-wave rectified. Following the smoothing and normalization protocols proposed by Chow et al,26, 27 average EMG levels for each muscle were determined for the push and recovery phases for each stroke cycle analyzed. Data Analysis For each slope and speed condition, the mean and SD were computed for each kinematic and EMG parameter. For each parameter, a 2-way analysis of variance (2 speeds × 7 slopes) with repeated measures was used to test for the significant difference for each factor (α<.05). When a significant difference was found in the slope condition, post hoc analyses were performed using the Tukey-Kramer procedure. The focus was placed on all combinations involving the level (ie, 0° and 2°, 0° and 4°, 0° and 6°). No adjustment in α level was made for multiple tests because of the exploratory nature of this study. Results Stroke Cycle Characteristics On average, the subjects increased their stroking speed by 39.1% when going from normal to fast speed (table 1). The stroke distance, stroke frequency, and relative recovery time increased significantly with increasing speed. On the other hand, the stroke time and relative push time decreased significantly with increasing speed. The speed, stroke time, stroke distance, and relative recovery time decreased significantly with increasing slope. Significant increases in stroke frequency and relative push time were observed when the slope increased. The post hoc analyses revealed significant differences between 0° and “4° and higher” (4+°) slopes in the stroke distance, relative push time, and relative recovery time, between 0° and 6+° in the stroke time, and between 0° and 8+° in the stroking speed and stroke frequency. Pushrim Kinematics The average contact angles were all negative and increased significantly (ie, less negative) with increasing slope (fig 3). Significant differences between speeds and across slopes were found in the release angle, and a significant difference across slopes was observed in the push angle. The post hoc analyses revealed significant differences between 0° and 8+° in the contact angle, between 0° and 10° in the release angle, and between 0° and 12° in the push angle. Trunk Kinematics At the instants of hand contact and hand release, significant differences were found in the trunk inclination between speeds and across slope conditions. A decrease in trunk inclination was observed as the slope increased (see fig 3). From 0° to 4° slope, there were minimum changes in the average inclinations of the trunk. In comparison with level pushing, significant differences were found between 0° and 8+° in the trunk inclinations at hand contact and release. At the instant of hand contact, significant differences across slopes and between the 2 speeds were found in the angular velocity of the trunk (see table 1). The post hoc analyses revealed a significant difference between 0° and 8+° in the angular velocity of the trunk at hand contact. At the instant of hand release, significant differences across slopes were found in the angular velocity of the trunk (see table 1). In general, the trunk was rotating backward at release and the magnitude increased with increasing slope. Compared with the level condition, significant differences were found between 0° and 6+° slopes in the angular velocity of the trunk at hand release. Muscle Activation Significant differences were found across different slopes in extensor carpi radialis for the push and recovery phases. In general, extensor carpi radialis activity for the recovery phase was greater than the corresponding value during the push phase, and the activity level increased with increasing slope (Fig 4, Fig 5). Extensor carpi radialis activity during the recovery phase was significantly higher in the fast speed trials than in the normative speed trials. Significant differences were found between 0° and 8+° slopes in extensor carpi radialis activity for the push phase and between 0° and 12° slopes in extensor carpi radialis activity for the recovery phase. Triceps brachii activity increased significantly with increasing slope and speed (see Fig 4, Fig 5). The post hoc analyses revealed significant differences between 0° and 6+° slopes in triceps brachii activity for the push phase and between 0° and 12° in triceps brachii activity for the recovery phase. Antero-middle deltoid activity increased significantly with increasing slope and speed (see Fig 4, Fig 5). In the normative speed trials, low-level activity (eg, <10% maximum) was found in the antero-middle deltoid throughout the stroke until the slope was increased to 6° to 8°. Significant differences were found between 0° and 8+° slopes in antero-middle deltoid activity for the push phase and between 0° and 10+° slopes in antero-middle deltoid activity for the recovery phase. Significant differences were found in postero-middle deltoid activity between different speed and slope conditions (see Fig 4, Fig 5). Postero-middle deltoid activity for the push phase was low except in fast speed–high slope trials. Initially, postero-middle deltoid activity during the recovery phase increased with increasing slope in both normal and fast speed trials and leveled off at slopes of 6° to 8°. For the comparisons involving the level condition, significant differences were found between 0° and 4+° in postero-middle deltoid activity for the recovery phase and between 0° and 8+° in postero-middle deltoid activity for the push phase. Very low pectoralis major activity was observed in the level normative speed trials (see Fig 4, Fig 5). Significant differences were found in pectoralis major activity between different speed and slope conditions. For both normative and fast speed conditions, pectoralis major activity during the push phase increased with increasing slope and leveled off at 8° slopes. Low pectoralis major activity was found in the recovery phase in most trials. For the comparisons involving the level condition, the post hoc analyses revealed significant differences between 0° and 4+° in pectoralis major activity for the push phase and between 0° and 12° in pectoralis major activity for the recovery phase. Significant differences were found in latissimus dorsi activity between the 2 speed conditions (see Fig 4, Fig 5). Although latissimus dorsi activity for both the push and recovery phases seemed to increase with increasing slope, significant differences across different slopes were found in the recovery phase, but not in the push phase. The post hoc analyses revealed significant differences between 0° and 8+° slopes in latissimus dorsi activity for the recovery phase and between 0° and 12° slopes in latissimus dorsi activity for the push phase. Discussion Limitations of this study include small sample size, 2-dimensional kinematics, and the fact that the sample consisted of fit, young men with paraplegia. Because the ability to push a wheelchair up a ramp is largely dependent on the upper-body strength of the wheelchair user, results of this study may not be generalized to wheelchair users of different ages and sexes. Because only 2-dimensional (sagittal view) kinematics were measured in his study, the effect of ramp slope on the lateral arm motion cannot be examined. In addition, the significant statistical differences should be interpreted with caution because of the potential errors associated with multiple tests. Regardless, the present study represents the first major effort in quantifying the kinematic and muscle activation characteristics of upslope wheelchair stroking under realistic conditions. Stroke Cycle Kinematics The decrease in stroking speed (1.29 to 1.13m/s) and increase in relative push time (46% to 51%) from the level to 8° slope are similar to the findings reported in the literature. However, our values are quite different from the changes from the level to 8° slope on ergometer Kulig et al14 reported (1.51 to 10.7m/s, 31.4% to 49.3%) and the changes in speed from the level to 6° treadmill grade reported by Richter et al10 (1.16 to 0.43m/s). Furthermore, instead of a significant decrease in stroke frequency with increasing slope as reported by Richter,10 we found a significant increase in stroke frequency as the slope increased (see table 1). The differences are likely related to the differences in test environment (ie, overground, ergometer, treadmill). Stroking speed is the ratio of stroke distance to stroke time. The decrease in speed with increasing slope was largely a result of reductions in stroke distance (see table 1). Because the speed can also be computed as the product of stroke distance and stroke frequency (reciprocal of stroke time), the results indicate that the increase in stroke frequency with increasing slope was not great enough to offset the decrease in stroke distance as the slope increased (fig 6). For the normative speed condition, our subjects maintained a relatively constant speed (≈1.25m/s) at lower slopes (ie, from the level to 6° slope) by varying the stroke distance and frequency (see fig 6). When going from normal to fast speed for the same slope, the increase in speed was accomplished by increases in both stroke distance and stroke frequency (see fig 6). With greater slopes, the increase in speed was primarily related to an increase in stroke frequency. Although the push time remained relatively constant across slopes (.46s [0°] to .56s [12°] for the normative speed condition and .35s [0°] to .36s [12°] for the fast speed condition), the relative push time increased steadily with increasing slope (see table 1). On the other hand, significant decreases in relative recovery times were found with increasing slope. It is very likely that the strategy of shortening the recovery time with increasing slope serves to prevent a significant loss in angular momenta of the wheels during the recovery because of the resistance (component of the weight of the wheelchair plus user that is parallel to the ramp surface). Pushrim Kinematics Our results on pushrim kinematics are quite different from findings based on data collected using a treadmill or a roller system. For example, the average push angle exhibited by our subjects during level stroking (47°) is greater than the corresponding values found by Rudins et al28 (25°–39° depending on chair type, stroking pattern, roller system) and much smaller than those reported by Koontz et al29 (100° and 110° for slow and moderate speeds, respectively, roller system) and Richter et al10 (108° to 81° from level to 6° treadmill grade). Richter10 also reported average decreases of 63%, 22%, and 26% in speed, stroke frequency, and push angle, respectively, when the treadmill grade was increased from level to 6°. In contrast, a 3% decrease in speed, a 4% increase in push angle, and an 18% increase in stroke frequency were observed between the level and 6° condition in the current study. These results suggest that there are differences in stroking mechanics between overground stroking on ramps and stroking on simulated slopes. As a result, findings from wheelchair propulsion data collected under nonoverground conditions need to be interpreted with caution. The significant increase in the contact angle with increasing slope (see fig 3) indicates that the hand contact occurred closer to the top dead center (see fig 2) as the slope increased. The changes in the release angle across different slopes were relatively small compared with the changes in the contact angle (see fig 3). Because the push angle is determined by the contact and release angles, the significant decrease found in the push angle with increasing slope was largely caused by the increase (less negative) in the contact angle. Trunk Kinematics The decrease in trunk inclination (increase in forward lean) at hand contact is probably one of the reasons for the increase in the contact angle with increasing slope (see fig 3). The forward lean helps to move the center of gravity forward to prevent backward tilt in higher slopes. For the same slope, the trunk inclination decreased when going from the normative to the fast speed condition. It has been suggested that an increase in forward lean would change the point of force application to the pushrim and promote the ability to transfer power to the pushrim from the trunk.30 The increase in forward lean and the strategy of shortening the recovery time with increasing slope to prevent a significant loss in angular momenta of the wheels during the recovery probably forced the subjects to adopt a more compact stroking pattern (ie, smaller push angle, higher stroking frequency) as the slope increased. At the instant of hand contact, both positive and negative angular velocities were observed in the trunk for the lower slopes. At higher slopes, the trunk rotated forward and the speed of rotation increased systematically. These results suggest that the trunk started to become actively involved in wheelchair propulsion when the slope was increased to 4° to 6° and 2° to 4° for the normal and fast speeds, respectively. Because trunk muscle activity was not recorded, direct evidence of active involvement is not available. At the instant of hand release, the increase in the trunk angular velocity with increasing slope was probably related to the increase in resistance to the pushing motion as the slope increased. At the end of the push phase, the reaction to the forceful extension of the arm against a heavy resistance caused the trunk to rotate backward. Muscle Activation The relatively large SD values found in the EMG measures reflect the individual differences among participants. During the push phase, extensor carpi radialis activity was probably associated with the grip on the pushrim. It is possible that the subject grasped the pushrim tighter in the higher slopes than in the lower slopes. Extensor carpi radialis activity in the recovery phase was a result of the wrist abduction. During the recovery phase, the wrist went from an adducted position (ulnar deviation) at hand release to an abducted position (radial deviation) at hand contact. At fast speed trials, quicker wrist abduction action was required because of the shorter recovery time. For subjects with paraplegia, triceps brachii activity during the push phase is expected because of its function as an elbow extensor. Low-level activity was also found in the triceps brachii during the recovery phase. It is possible that, during the recovery phase, the long head of triceps brachii assisted the teres major and latissimus dorsi in drawing the humerus backward (shoulder extension) and inward (shoulder adduction). The increase in antero-middle deltoid activity at higher slopes may be related to the forward lean trunk position. During the recovery phase, the antero-middle deltoid underwent eccentric contractions and assisted in bringing the arm inward (shoulder adduction). It was also possible that antero-middle deltoid activity found in the recovery served to stabilize the shoulder joint. Cocontractions of antero-middle and postero-middle deltoids were observed in both push and recovery phases. Because a number of muscles are involved in shoulder joint movements, the exact roles of antero-middle and postero-middle deltoids during wheelchair propulsion cannot be determined without knowing the actions of the other muscles. One speculation is that the deltoids help to position the upper arm so that the rotator cuff muscles can stabilize the shoulder joint more effectively.20 The pectoralis major was most active during the midportion of the push phase, presumably serving to flex the humerus (clavicular portion of the pectoralis major). The increase in pectoralis major activity during the push phase with increasing slope and speed are probably associated with the increase in resistance to shoulder flexion during the push phase. These results suggest that the contribution of the pectoralis major in wheelchair propulsion was minimum at low-speed level stroking. However, the pectoralis major became heavily involved during upslope and high-speed stroking. Similar to the findings of Cerquiglini et al,13 the latissimus dorsi was most active toward the end of the push phase and at the beginning of the recovery phase. At the end of the push phase, the latissimus dorsi probably assisted in bringing the upper arm toward the torso (shoulder adduction) and slowing the motion of the upper arm. During the early recovery phase, the latissimus dorsi helped to draw the upper arm backward (shoulder extension) when the upper arm was located in front of the trunk. The physically fit men with paraplegia in our study can easily traverse ramps permitted in the ADAAG (up to 4.8° for a ramp length of 9.1m). However, that may not be the case for wheelchair users with limited muscular strength and/or trunk function (eg, high-level spinal cord injury). Future studies should explore the biomechanics of upslope stroking for different wheelchair user populations. Conclusions The results support our hypothesis that stroking upslope is associated with greater activation in upper-extremity and upper-trunk muscles. Our subjects started to alter their kinematic and muscle activation patterns significantly when the slope was increased to about 6°. Major kinematic changes associated with increasing slope include decreases in stroking speed and relative recovery time, and increases in stroke frequency, forward lean, and angular velocity of the trunk. Our subjects used the strategy of compact stroking pattern (ie, increased forward lean, smaller push angle, higher stroke frequency, and shortened recovery time) as the slope increased. Among the muscles monitored in this study, triceps brachii, antero-middle deltoid, and pectoralis major had their primary activity during the push phase of upslope stroking. The postero-middle deltoid was found to be a recovery muscle, and both the extensor carpi radialis and latissimus dorsi were equally active in both the push and recovery phases. In addition to endurance training for maintaining optimum muscle function,20 wheelchair users will also benefit from strength training that targets upper-extremity and paraspinal muscles for greater capacity to negotiate ramps. Suppliers Acknowledgments We thank Abiola Awe, Dan Davis, Rebecca Kozlowski, Hetal Patel, and Doug Sohn for their assistance in different aspects of this project. References 1. 1Architectural and Transportation Barriers Compliance Board. Americans with Disabilities Act accessibility guidelines for buildings and facilities (ADAAG). Washington (DC): US Access Board; 1998;. 2. 2Lehmann JF, Warren CG, Halar E, Stonebridge JE, DeLateur BJ. Wheelchair propulsion in the quadriplegic patient. Arch Phys Med Rehabil. 1974;55:183–186. MEDLINE 3. 3Steinfeld E, Schroeder S, Bishop M. Accessible buildings for people with walking and reaching limitations. 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a Center for Neuroscience and Neurological Recovery, Methodist Rehabilitation Center, Jackson, MS b Division of Rehabilitation Education, University of Illinois at Urbana-Champaign, Urbana, IL c Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL d Department of Physical Education, Kyung Pook National University, Daegu, Korea e Division of Sport Science, Konkuk University, Chungju, Korea  Reprint requests to John W. Chow, PhD, Center for Neuroscience and Neurological Recovery, Methodist Rehabilitation Center, 1350 E Woodrow Wilson, Jackson, MS 39216
Supported by the Mary Jane Neer Research Fund. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. PII: S0003-9993(08)01585-2 doi:10.1016/j.apmr.2008.07.019 © 2009 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved. | |
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