Archives of Physical Medicine and Rehabilitation

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Archives of Physical Medicine and Rehabilitation 2015;-:-------

ORIGINAL RESEARCH

Promoting Physical Activity Through a Manual

Wheelchair Propulsion Intervention in Persons With
Multiple Sclerosis
Ian M. Rice, PhD, Laura A. Rice, PhD, Robert W. Motl, PhD
From the Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana, IL.

Abstract
Objective: To examine the efficacy and feasibility of a multifactorial intervention to increase lifestyle physical activity in nonambulatory persons
with multiple sclerosis (MS) based on wheelchair optimization, propulsion skill/technique training, and behavioral strategies based on social
cognitive theory.
Design: Randomized controlled trial, 3-month postintervention follow-up.
Setting: Home and general community, and university research laboratory.
Participants: Nonambulatory individuals with MS (NZ14; mean age
SD, 53.6
8.7y) were randomly assigned to an intervention group (IG) or
a control group (CG).
Interventions: After baseline testing, the IG participants received custom-fit, ultralightweight manual wheelchairs with propulsion/skills
training, followed by 3 months of at-home use with the custom ultralightweight wheelchair and weekly phone calls to deliver support through a
multifactorial intervention. The CG participants received no training and used their own wheelchairs at home during this time.
Main Outcome Measures: All subjects were assessed at baseline and 3 months later for fatigue (Fatigue Severity Scale), upper extremity strength
(digital handheld dynamometer), and propulsion technique (on a treadmill [0.5m/s] with instrumented wheels). Two 1-week bouts of physical
activity were measured in both groups from home with wrist-worn accelerometry at the beginning (IG and CG in own wheelchairs) and end (IG in
study wheelchair, CG in own) of the 3-month period of home use.
Results: The intervention was well tolerated, and no adverse events were reported. The IG demonstrated increased strength (PZ.008) and a trend
toward less fatigue (PZ.068), both with large effect sizes (d>0.8), as well as reduced application of braking torque during propulsion (PZ.003)
with a moderate/large effect size (dZ.73), compared with the CG.
Conclusions: Findings suggest a 3-month physical activity intervention based on manual wheelchair propulsion and training is safe and feasible
for some wheelchair users living with MS and may produce secondary benefits in strength, fatigue, and propulsion technique.
Archives of Physical Medicine and Rehabilitation 2015;-:------ 2015 by the American Congress of Rehabilitation Medicine

There is increasing evidence regarding the importance of physical

activity (PA) among persons with multiple sclerosis (MS).1 PA is
defined as bodily movement produced by contraction of skeletal
muscles that results in increased energy expenditure,2 and can be
accumulated as part of ones everyday life.3 This lifestyle PA can be
measured objectively using body-worn accelerometers,4 and has
been associated with subclinical and self-reported cardiovascular
health,5,6 walking mobility,7 information processing speed,8
Supported by the National Multiple Sclerosis Society, Illinois Department of Public Health,
Office of Health Promotion, Division of Chronic Disease Prevention and Control (grant no. IL
0005).
Disclosures: none.

symptoms of fatigue,9 depression, pain,10,11 and quality of life12

in MS. PA further can be transformed through multifactorial interventions that provide participants with the necessary resources,
skills, and strategies for successful health behavior change. To date,
such interventions have been delivered using the Internet,10 telephone,13 and pamphlets,14 and successfully increased PA with secondary benefits for symptoms. However, these interventions have
only been delivered among ambulatory persons with MS, and little is
known regarding their feasibility, safety, and efficacy when used for
increased PA among mobility device users with severe MS.3
Despite the documented benefits of PA, many persons living
with MS are physically inactive and sedentary, and this is

0003-9993/15/$36 - see front matter 2015 by the American Congress of Rehabilitation Medicine
http://dx.doi.org/10.1016/j.apmr.2015.06.011

I.M. Rice et al

particularly salient among nonambulatory individuals. For

example, both worsening symptoms and increased levels of
disability have been associated with reduced PA.15,16 Additionally,
those using mobility devices often find unique challenges to
accessing safe and effective methods of exercise.
Consequently we wondered whether delivering a multifactorial
intervention based on manual wheelchair propulsion (MWP) for
nonambulatory persons with MS could be successful if the proper
technology and training were provided. MWP was selected over
formal exercise training to determine the extent to which it affords
individuals the flexibility to choose the time, duration, and environment in which activity occurs, along with offering those who
experience fatigue the convenience of combining exercise and
community participation.
This randomized, controlled pilot study examined the efficacy
and feasibility of the intervention among nonambulatory persons
with MS. We hypothesized that the intervention group (IG) would
tolerate MWP with few adverse events and increase PA levels
based on wrist accelerometer vector counts. We further hypothesized secondary benefits in propulsion technique, upper limb
strength, and fatigue in the IG compared with a control group (CG).

Methods
Participants
Participants were recruited through the North American Research
Committee on MS, phone calls to previous research participants,
and local MS Society events. Twenty participants were then
screened over the telephone for the following inclusion criteria:
(1) diagnosis of MS (later confirmed by participants physicians);
(2) full-time wheelchair user (use of power or manual for >40h/
wk and >80% ambulation); (3) aged 18 to 64 years; (4) stable
health status for the past 3 months; and (5) bilateral gross upper
extremity strength of at least 4-/5 (acquired later at University of
Illinois at Urbana-Champaign labs). Exclusion criteria were as
follows: (1) wheelchair athletes; (2) orthopedic upper extremity
impairment; (3) self-reported history of cardiovascular or cardiopulmonary disease; and (4) pressure ulcers. Of those initial 20
interested participants, 6 were excluded (3 did not use a wheelchair full time, and 3 were unable to travel).

Study design/procedures
Overview
The local institutional review board approved all experimentation.
Participants were randomly assigned to either an IG or a CG on a
2:1 ratio to best characterize the IG, but still have data on test
stability and administration from the CG (fig 1). Participants (IG
and CG) visited the university labs 2 times, for baseline (visit 1)
and posttesting (visit 2) (fig 2).

List of abbreviations:
CG
FSS
IG
MS
MWP
PA
RESNA

control group
Fatigue Severity Scale
intervention group
multiple sclerosis
manual wheelchair propulsion
physical activity
Rehabilitation Engineering Society of North America

Intervention group
During visit 1, IG participants were examined for upper limb
strength and fatigue. Next they received seating evaluations to
configure the study wheelchair (ICON A1 wheelchaira) to meet
their needs. Next, baseline propulsion biomechanics were recorded followed by technique/safety training. The IG participants
were then given the ICON for 3 months of home use and
encouraged to incorporate it into their daily lives. Example activities were provided to help them achieve this endeavor. During
home use, wrist-worn accelerometers were sent through the mail
to record two 1-week bouts of PA at the beginning and end of the
3-month period (see fig 2). Bout 1 consisted of activity using their
primary mobility device(s) (not the ICON), while bout 2 recorded
activity with the ICON. Finally, IG participants returned to the lab
3 months after visit 1 for follow-up testing identical to baseline.
Study wheelchair
The ICON A1 wheelchair is a rigid, ultralightweight, aluminumframed manual wheelchair meeting Rehabilitation Engineering
Society of North America (RESNA)/American National Standards
Institute voluntary standards. This chair was selected because it
offered the flexibility to meet the standards set forth by RESNA in
a position paper17 on the application of ultralight manual wheelchairs. These standards include durability, adjustability, customization, and the ability to meet the specific mobility and postural
needs of the intended user. The ICON is fully adjustable (eg,
width, length, footrest height, seat/back angle, center of gravity,
back height) and weighs <25lb with rear suspension (fig 3A and
B). All ICON wheelchairs had 25-in quick release rear wheels
with pneumatic tires and 4-in-diameter front caster wheels. An
external contoured aluminum back supportb was attached for
added postural support, and Varilite seat cushionsc were provided.
Training
Safety and technique training were provided to IG participants by
an occupational therapist and a licensed physical therapist with an
Assistive Technology Professional certification. An instructional
multimedia presentation used previously was presented as well.18
The multimedia presentation guidelines are consistent with the
recommendations published by the Consortium for Spinal Cord
Medicine to prevent upper limb pain and injury.19 Manual
wheelchair users are encouraged to use low-frequency, long and
smooth strokes (large contact angle) during the propulsive phase
to decrease the force exerted at a given velocity.19 Additionally,
subjects are encouraged to match the speed of the handrim on
contact to minimize braking torques that slow the wheel.
Behavioral intervention
Based on social cognitive theory,20 the behavioral intervention
was delivered through weekly phone calls by a physical therapist
to IG participants, during which strategies for initiation and
maintaining PA with the ICON were taught. Such strategies
included self-monitoring, goal setting, planning, optimizing
outcome expectations, enhancing self-efficacy, overcoming barriers, and identifying facilitators.
Wheelchair data logger manipulation check
Only the IG members ICON wheelchairs were equipped with
data loggers to ascertain the 3 months of home use. Additionally,
the data logger allowed researchers to determine whether wrist
accelerometer vector counts accumulated during the second
1-week period of home use resulted from ICON use or their own
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Physical activity intervention

Fig 1

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Consolidated Standards of Reporting Trials (CONSORT) diagram.

I.M. Rice et al

Fig 2

Study design and time frame.

wheelchairs (IG was instructed to use the ICON). We used the

SHR100 portable triaxial accelerometer,d which captures
distance traveled, time spent in propulsion, and propulsion speed.
The 6ecubic inch device weighs 75g and was mounted underneath the seat pan of each ICON, effectively invisible to
participants.
Control group
During visit 1, CG participants received baseline measures of
upper limb strength and fatigue. Next they were fitted to the ICON
and received propulsion testing on a treadmill in the ICON, followed by a rest period and a repeat testing to compare with the IG
participants who received technique training. The CG participants
were then asked to continue to use their primary mobility devices
for 3 months at home. Wrist-worn accelerometers were sent
through the mail to be worn for two 1-week periods, the same as

the IG. Finally, CG participants returned to the lab 3 months later

for follow-up testing identical to visit 1.

Instruments/measures
Wheelchair propulsion testing
Propulsion testing was performed on a motorized wheelchair
treadmill at a target speed of 0.5m/s.21 Two 25-inch-diameter
SmartWheelse were used to record the 3-dimensional forces and
moments applied to the wheelchair handrim at a sampling frequency of 240Hz. Peak resultant force (N), contact angle (degrees), stroke frequency (strokes/s), and braking torque (N) were
calculated with SmartWheel commercial software.e These variables were selected because of their association with the development of upper extremity pain and injury. Specifically, an

Fig 3 Study wheelchair (ICON) adjustability versus hospital (depot) style wheelchair. (A) ICON: rearward center of gravity configuration (easier
to propel), greater seat angle, low floor-to-seat height. (B) ICON: forward center of gravity configuration, level seat angle, greater floor-to-seat
height. (C) Depot wheelchair: most common wheelchair used by persons with MS, heavy (>36lb), and nonadjustable. Used with permission from
Icon Wheelchairs, Inc.

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Physical activity intervention

increased contact angle with a reduced peak resultant force, stroke
frequency, and braking torque constitute more optimal technique.
ActiGraph wrist accelerometer
ActiGraph model GT3X accelerometersf provided an objective
measurement of daily PA during two 1-week bouts of wheelchair
use. A linear association has been found between energy expenditure and accelerometer counts for estimating the time spent in
moderate to vigorous PA during MWP using wrist-worn accelerometry.22 This accelerometer was worn like a wristwatch during
waking hours of a 7-day period where the total vector count was
summed and interpreted identical to methods described previously.23,24 Baseline vector counts were obtained from both groups
(IG and CG) using the participants own wheelchairs at home first.
Although the IG was sent home with an ICON, they were
instructed not to use it for the first week so we could compare the
baseline vector counts. Next, the IG participants switched to the
ICON for 3 months of intermittent use, while the CG participants
continued to use their own wheelchairs. After 3 months, another 1week period of wrist accelerometry was recorded (IG in ICON,
CG in own wheelchair).
Upper extremity manual muscle testing
The micro FET 2 wireless digital handheld dynamometerg was
used to assess unilateral upper extremity strength at baseline and 3
months later. The nondominant side was selected because it has
been shown to be more impaired in some persons with MS and
therefore more likely to interfere with wheelchair propulsion.25
The muscle groups tested were those shown to be most critical
to propulsion.26 Participants were tested from the same lab
wheelchair using the break methodology. Resistance was
applied to overcome maximum effort, causing the joint to move in
the opposite direction (eccentric muscle contraction).27 The mean
of 3 repetitions was analyzed per muscle group.
Fatigue
The Fatigue Severity Scale (FSS)28 was administered at baseline
and 3 months later. The FSS is a unidimensional 9-item questionnaire capturing the impact and severity of MS fatigue, where
higher scores (4) reflect more severe perception of fatigue. The
FSS has good evidence of internal consistency, test/retest reliability, and score validity.

Statistical analysis
All analyses were performed in SPSS version 22.h Differences in
demographic/clinical characteristics were examined using
independent-samples t tests for continuous variables and chi-square
analyses for categorical variables. To examine the effects of the
intervention on outcome variables (muscle strength, fatigue, wrist
accelerometer data), we performed 2-by-2 (group-by-time) mixedfactor analyses of variance. A repeated-measures mixed analysis of
variance was used to examine wheelchair propulsion metrics.
Because of multiple comparisons, a Bonferroni correction was performed to control for an inflated type I error where the alpha level
used to judge statistical significance was set to .0125 (.05/4). Because
of the small sample size, emphasis was placed on calculating effect
sizes per outcome measure as suggested by Rutledge and Loh.29 Even
small effect sizes can have important clinical implications and may
be a more accurate measure of the result of the experimental
manipulation when the sample size is small.29,30 Effect size (d )
associated with the intervention was calculated using Cohens
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5
Table 1

Demographic characteristics

Characteristics

CG (nZ5)

IG (nZ9)

Age (y)
Sex (M/F)
Time with diagnosis (y)
Type of MS
SP
RR
PP

54
0.4
1/4
17.6
8.5

53.3
11.1
3/6
13.2
8.9

2
2
1

4
3
2

NOTE. Values are mean
SD or n. Mean
SD values are based on

independent-samples t tests for continuous variables and chi-square
for categorical variables. No statistically significant differences between groups were observed (P>.05).
Abbreviations: F, female; M, male; PP, primary progressive; RR,
relapsing-remitting; SP, secondary progressive.

d (difference in mean scores over time divided by pooled SD) and was
interpreted as small (d0.2), moderate (d w0.5), and large (d0.8).

Results
Demographic characteristics
Demographic characteristics are presented in table 1. Clinically,
participants reported having relapsing-remitting (nZ5), secondary
progressive (nZ6), and primary progressive (nZ3) MS. After
randomization, age, years with diagnosis, sex, and disease type
were not significantly different between groups ([t12Z0.1, PZ.8],
[t12Z0.8, PZ.3], [c21Z.28, PZ.545], and [c22Z.062, PZ.97],
respectively).
Because of equipment malfunction and participant preferences
not to transfer, some data were lost. Two CG participants were
reluctant to transfer into the ICON and therefore did not participate
in propulsion or manual muscle testing; however, they did complete
fatigue and accelerometer testing. In addition, wrist accelerometer
malfunction occurred in 1 IG and 1 CG participant, reducing the n
value to 8 for the IG and 4 for the CG (see tables 1-5).

Wrist accelerometer
Wrist accelerometer data are presented in table 2, which includes
mean
SD values, percent change, and effect size. A statistically
significant group-by-time interaction was not found for activity
counts at the wrist (F1,10Z.217, PZ. 651, partial h2Z.021).
However, the IG displayed a larger percent increase than did the
CG (13.3% vs 6%).

Wheelchair propulsion
Propulsion metrics are presented in table 3, which includes mean

SD values and effect sizes. The IG demonstrated reduced braking
torque (F1,9Z16.8, PZ.003, h2Z.65) and stroke frequency
(F1,9Z3.4, PZ.09, h2Z.27) (approaching significance), with large
effect sizes compared with the CG from baseline to follow-up.

Manual muscle testing

Manual muscle testing data are presented in table 4, which includes mean
SD values, percent change, and effect sizes.

I.M. Rice et al
Table 2

Activity counts with wrist accelerometer

Group

Baseline

3mo

% Change

Cohens d*

Effect Size

CG (nZ4)
IG (nZ8)

923,499.3
475,384.4
980,428.9
547,676.5

979,454.1
639,999.5
1,111,080.1
510,500.4

6.0[
13.3[

.14

Approaching small

NOTE. Values are mean
SD or as otherwise indicated. The wrist accelerometer used was an ActiGraph model GT3X accelerometer.
Abbreviation: [, increase.
* Cohens d calculated mean change/pooled SD at baseline (range: 0.2 small, 0.5 moderate, 0.8 large).

Statistically significant group-by-time interactions were observed

for the pectoralis major (F1,10Z11.0, PZ.008, partial h2Z.526),
while strength gains approaching significance occurred at the
middle deltoid (F1,10Z3.68, PZ.084, partial h2Z.26).

Fatigue
FSS results are presented in table 5. There was a group-by-time
interaction for fatigue that approached statistical significance
with a large effect size (F1,12Z4.0, PZ.068, partial h2Z.25).

Wheelchair data logger manipulation check

Wheelchair data logger results are presented in figure 4. Data are
based on 7 IG members because 2 devices malfunctioned.
Figure 4 represents the group averages (bars) and individual
weekly distance traveled (lines) at 1-, 2-, and 3-month time points.
Month 1 corresponds to the first month of ICON use in the IG. The
data suggest that the wheelchairs were generally used, but with
considerable variability. Based on group averages, participants
were most active the first month, which declined in month 2 and
increased slightly in month 3.

Safety/feasibility
IG participants were asked to describe their experience with the
ICON wheelchairs, and no adverse events were reported. IG
members reported that the ICON wheelchairs were lightweight
and comfortable, made mobility easier, and enabled them to
achieve and maintain speed. However, those performing standing
pivot transfers reported that the fixed footplate interfered with
standing. Swing-away footrests were their preference. Those who
performed sitting pivot transfers were unaffected. In addition,
some found the nonfolding frame and antitippers interfered with
car transport, making them less willing to travel. Also, some reported difficulties managing the hideaway locking brakes.

Table 3

Discussion
The purpose of this study was to evaluate the feasibility, safety, and
efficacy of a multifactorial lifestyle PA intervention for persons
with severe MS. We believe this to be the first experimental attempt
to examine an intervention for increased PA in this population.
Despite the preliminary nature of the study, intervention outcomes
were encouraging and may offer insights into the design of methods
to improve PA in a population where research is scarce.
The current study design did not allow for the determination of
which interventional component (optimization, training, behavioral
intervention) led to improvements, only the systems influence as a
whole, which is a limitation. However, as a preliminary study,
safety was a primary concern, where providing an extremely
responsive wheelchair to novice users without training/support in
order to separate the influence of the behavioral intervention or the
ICON was deemed unnecessarily risky. Instead, our goal was to
deliver a balanced approach offering IG subjects more supportive
conditions compared with a CG receiving the standard of care. It
was our intention to learn from participants reactions to improve
the study design for future, sufficiently powered investigations.
Consistent with our hypothesis, the intervention was well tolerated and no adverse events occurred. Additionally, moderate to large
effects sizes were observed, signifying favorable changes in aspects
of propulsion technique, upper extremity strength, and trends toward
reduced fatigue. Because fatigue has been cited as a primary factor
precluding individuals with MS from propulsion,31 this trend was
encouraging. Although strength measures should be interpreted
cautiously, the strength increase observed in the pectoralis major
may be of interest because it has been identified as both a primary
contributor to propulsion and as a muscle specifically shown to fatigue in some wheelchair users with MS during propulsion.32
Fundamental to our intervention was use of a custom-fit,
ultralightweight high-performance wheelchair, intended to
maximize ease of propulsion. Consistent with RESNAs recommendations, each ICON was customized to participants needs
while preserving its lightweight.17 Our IG participants learned to

Wheelchair propulsion biomechanics

CG (nZ3)

IG (nZ9)

Performance Variables

Baseline

3mo

Baseline

3mo

Cohens d

Effect Size

Peak resultant force (N)

Contact angle (deg)
Frequency (strokes/s)
Braking force (N)

37.7
10.4
32.4
1.3
1.0
0.1
7.3
3.3

54.6
11.2
38.9
6.8
1.0
0.1
8.1
3.4

46.1
20.0
43.9
16.3
0.8
0.1*
5.6
1.9y

45.8
12.9
46.2
15.1
0.79
0.2*
2.9
1.1y

1.04
0.36
0.1
0.73

Large
Small/moderate
Small
Moderate/large

NOTE. Values are mean
SD or as otherwise indicated. Mean
SD values are based on repeated-measures multivariate analysis of variance. Target
speed condition 0.5m/s.
* P<.09.
y
P<.0125.

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Physical activity intervention

Table 4

Upper extremity muscle strength

CG (nZ3)

IG (nZ9)

Muscle Group

Base

3mo

% Change

Base

3mo

% Change

Cohens d*

Effect Size

Anterior deltoid
Middle deltoid
Latissimus dorsi
Pectoralis major
Triceps
Biceps

23.1
5.4
24.4
1.3
23.9
5.1
16.0
4.8
22.9
0.3
24.1
3.3

23.4
7.2
24.0
7.5
23.6
11.0
14.4
7.0
24.6
3.3
25.9
10.2

1.2 [
1.6 Y
1.2 Y
10.0 Y
7.4 [
7.4 [

19.7
3.3
18.6
3.3
22.2
4.3
12.5
2.5
24.3
4.3
25.6
6.5

22.2
4.4
22.2
4.4y
25.2
5.7
14.2
2.9z
21.9
2.6
26.5
5.5

2.5 [
19.3 [
13.0 [
13.6 [
9.8 Y
3.5 [

0.5
1.2
0.5
0.86
0.23
0.17

Moderate
Large
Moderate
Large
Small
Small

NOTE. Values are mean
SD or as otherwise indicated. All mean
SD values are based on mixed analysis of variance. Upper extremity muscle strength
was determined using the micro FET 2 wireless digital handheld dynamometer.
Abbreviations: [, increase; Y, decrease.
* Cohens d calculated mean change/pooled SD at baseline (range: 0.2 small, 0.5 moderate, 0.8 large).
y
P<.09.
z
P<.0125.

use fewer strokes to maintain speed while applying less braking

torque, meaning they learned to contact the handrim smoothly
without slowing the wheel down. While our participants improved,
compared with active wheelchair users with spinal cord injury, our
IG participants propelled slower and did not travel as far.33 This
lends support to the notion that MWP may be of benefit to users
with MS for short distances.34 Additionally, our participants were
novice users, and most of the related literature is focused on
experienced manual wheelchair users; therefore, comparisons
should be perceived with caution. Longer follow-up with continued
use could help determine whether our participants could achieve
similar levels of activity. Importantly, the perception that persons
with MS should not self-propel may stem from the fact that most are
prescribed Healthcare Common Procedure Coding System K0001
manual wheelchairs (fig 3C), which are extremely difficult to
propel and not designed for independent mobility.35 Persons with
MS often receive inferior wheelchairs because of strict regulations
pertaining to eligibility and medical necessity, in addition to the
perception that manual chairs will be used briefly as an intermediate step to power devices as the disease progresses.36
Although the study intervention led to favorable propulsion
changes compared with the CG, the data logger manipulation check
revealed considerable variability in ICON usage (distance traveled). Possible explanations could include lack of motivation,
symptom fluctuation, weather, and transportation. Use of additional
theoretical strategies to improve behavior change may have facilitated increased PA. For example, use of Internet-delivered interventions based on social cognitive theory to increase PA has been
effective in persons with less severe MS and could be easily
adopted.37,38 Similarly, some of our participants were unable to use

Table 5

the ICON because of difficulties transferring into it. We learned that

a ridged footplate prevents some from transferring weight over their
legs during a standing pivot transfer. In the next phase of this study
it will be imperative to modify aspects of the wheelchair, such as the
footplate, to safely accommodate more individuals.
Improved methods of capturing PA will also be necessary in
future investigation. For example, all participants showed
increased vector counts at the wrist, although the IG change was
double that of the CG. While the magnitude of difference between
groups was large, the small sample size combined with the short
time frame to capture PA (two 1-week periods) may have influenced the results. The use of accelerometers able to capture
months of PA rather than weeks could help identify trends and
minimize the impact of symptom fluctuations, which have been
shown to influence an individuals desire to engage in PA.39
Additionally, the accelerometers used to quantify upper limb activity could not distinguish upper limb motions specific to propulsion from those occurring naturally during activities of daily
living. We are currently developing methods to distinguish between these signals that will allow for a more precise estimation of
PA accumulated through propulsion.

Fatigue Severity Scale*

Baseline

3mo

CG (nZ5)

IG (nZ9)

CG (nZ5)

IG (nZ9)

Cohens
dy

Effect
Size

5.2
1.5

5.7
1.2z

5.6
0.8

4.6
1.9z

1.15

Large

NOTE. Values are mean
SD or as otherwise indicated. All mean
SD

values are based on mixed analysis of variance.
* FSS score range from 1 (least fatigue) to 7 (most severe fatigue).
y
Cohens d calculated mean change/pooled SD at baseline (range:
0.2 small, 0.5 moderate, 0.8 large).
z
Approaching significance between groups, P<.09.

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Fig 4 IG wheeling distance at home with ICON. Data based on

weekly average of 7 IG participants. Colored lines represent IGs
average weekly distance traveled over 3 months; gray bars represent
IG group means where Month 1 Z 888.5 (953.9) feet, Month 2 Z
661.0 (637.9) feet, and Month 3 Z 702.9 (1130.3) feet, while black
bars constitute standard error values associated with these means.

Study limitations
As the current pilot study was a first step, inherent limitations
exist. The primary limitation of the current study is evident in the
use of a small sample size to examine numerous outcome measures. Because this was an early-phase study, the importance of
effect sizes cannot be overstated. A multisite design or the ability
to test remotely may increase enrollment in future studies.
Another limitation is evident in our lack of knowledge regarding
participants usage of their own wheelchairs because only the
ICON wheelchairs were instrumented. We plan to monitor multiple mobility devices in the future. Additionally, these results may
not generalize to all nonambulatory persons with MS because our
participants possessed a minimum level of upper limb strength.
The extent to which others with less strength could benefit from a
similar intervention is unclear and warrants investigation. In
addition, wheelchair propulsion measures were recorded at a
target speed during level treadmill propulsion that may not
represent users technique in the community. Finally, data
collection occurred over 10 months in central Illinois where the
weather may have influenced participants activity levels
differently.

Conclusions
Preliminary findings suggest that a PA intervention based on
wheelchair optimization, training, and a behavioral intervention is
feasible for some individuals with MS and may produce secondary benefits in strength, fatigue, and propulsion technique.
Both groups increased PA levels, with the IG showing a larger
percent change; however, differences were not statistically significant.

Suppliers
a. ICON A1 wheelchair; Icon Wheelchairs, Inc.
b. External contoured aluminum back support; Accessible Designs, Inc.
c. Varilite seat cushions; Varilite.
d. SHR100 portable triaxial accelerometer; Autonomous
Innovations.
e. SmartWheels; Out-Front.
f. ActiGraph model GT3X accelerometer; Actigraph Corp.
g. Micro FET 2 wireless digital handheld dynamometer; HOGGAN Scientific, LLC.
h. SPSS version 22; SPSS Inc.

Keywords
Fatigue; Motor activity; Multiple sclerosis; Rehabilitation; Quality
of life; Wheelchairs

Corresponding author
Ian M. Rice, PhD, Department of Kinesiology and Community
Health, University of Illinois at Urbana-Champaign, 332 Freer
Hall, Urbana, IL 61801. E-mail address: ianrice@illinois.edu.

I.M. Rice et al

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