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Applied Ergonomics 34 (2003) 571579

Folding and unfolding manual wheelchairs: an ergonomic evaluation of health-care workers$

Heather A. Whitea, R. Lee Kirbyb,*
b a School of Health and Human Fitness, Faculty of Health Professions, Dalhousie University, Halifax, NS, Canada Division of Physical Medicine and Rehabilitation, Faculty of Medicine, Dalhousie University, Rehabilitation Centre Site, Queen Elizabeth II Health Sciences Centre, 1341 Summer Street, Halifax, NS, Canada B3H 4K4

Received 15 February 2002; received in revised form 6 June 2003; accepted 15 June 2003

Abstract The objective of this study was to test the hypotheses (i) that health-care workers vary greatly in the methods used to fold and unfold selected manual wheelchairs, and (ii) that many of the methods used include bent and twisted back postures that are known to be associated with a high risk of injury. We studied 20 health-care workers in a rehabilitation center. Subjects folded and unfolded two wheelchairs of cross-brace design, one with and one without a sling seat. As outcome measures, we used a questionnaire, time taken, visual analog scales of perceived exertion and back strain, folded width, videotape and Ovako Working Posture Analysis System (OWAS) back scores (14). Subjects used up to 14 different combinations of approach, hand placement and back posture to accomplish the tasks. The mean OWAS scores were in the 2.43.1 range and 49 (42%) of the 118 scores recorded were class 4 (back simultaneously bent and twisted, considered to be associated with the highest risk of injury). We also observed methods that appeared to be safe and effective. Age, gender, profession, experience and seat condition did not generally inuence the outcome measures. We conclude that health-care workers use a variety of methods to fold and unfold wheelchairs, many of which include bent and twisted back postures that may carry a risk of injury. Further study is needed to conrm this risk, to identify more ergonomically sound wheelchair designs and to develop better methods of carrying out the common and important task of folding and unfolding wheelchairs. r 2003 Elsevier Ltd. All rights reserved.
Keywords: Ergonomics; Prevention; Low back pain; Health-care workers; Wheelchairs

1. Introduction Jones and Sanford (1996) projected that there would be 2 million wheelchair users in the United States in 2000. The ability to fold a manual wheelchair into a narrow position for easier transport and storage is a popular design feature (Deitz and Dudgeon, 1995; Kirby, 1997; Cooper, 1998). The cross-brace design (Fig. 1), invented by Herbert Everest and Harry Jennings in 1932 (Cooper, 1998) and now available from most wheelchair manufacturers, is still the most commonly used by community wheelchair users and in the hospital and rehabilitation settings.
Partial funding was received from the Workers Compensation Board of Nova Scotia. *Corresponding author. Tel.: +1-902-473-1268; fax: +1-902-4733204. E-mail address: kirby@dal.ca (R. Lee Kirby). 0003-6870/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0003-6870(03)00079-6
$

Although there is an extensive literature on many aspects of wheelchairs and their use (e.g., acute and overuse injuries of wheelchair users, wheelchair performance), surprisingly little attention has been paid to wheelchair ergonomics. In a search of English-language articles cited by Medline from January 1, 1950 to June 1, 2003, we identied 123 articles in response to the search terms wheelchair AND ergonomics and 13 from the search terms wheelchair AND folding, but none dealt specically with the tasks of folding and unfolding manual wheelchairs by people other than wheelchair users or the associated risk of injury. The reported success rates for folding/unfolding manual wheelchairs, as a component of the Wheelchair Skills Test, range from 5% to 88% for groups of wheelchair users, ablebodied subjects, occupational therapy students at different levels of training and untrained caregivers (Kirby et al., 2002, 2003a, b; Coolen et al., 2002). The methods used were not reported.

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Fig. 1. Cross-braced wheelchair, open (A) and folded (B).

Low back pain (LBP) accounts for 33% of all compensation, 4.6 billion dollars each year in the United States (van Oort et al., 1990). The individual risk factors for the development of LBP that have been explored in the literature include age, gender, anthropometric characteristics, physical tness, smoking, psychological factors and previous history of LBP (Biering-Sorensen, 1983; Agnew, 1987; Burton and Cassidy, 1992; Garg and Moore, 1992; Khalil et al., 1993). The work-related risk factors reported include heavy work and lifting, static work postures, twisting and bending postures, vibration, perceived exertion and perceived back strain (Stubbs et al., 1983; Videman et al., 1984; Snook, 1985; Harber et al., 1985; Agnew, 1987; Burdorf et al., 1991; McAtamney and Corlett, 1992; Borenstein et al., 1995). Health-care occupations frequently require bending, twisting and lifting postures (Harber et al., 1985; Jensen, 1987; McAtamney and Corlett, 1992; Knibbe and Friele, 1996, Hignett, 1996; Woolfrey and Kirby, 1998; Cromie et al., 2000; Elford et al., 2000; Hui et al., 2001; Daynard et al., 2001). Jensen (1987) reported that health-care occupations constituted 6 of the top 10 ranked occupations for the incidence of LBP. In clinical practice, we have noted that many health-care workers approach the task of folding and unfolding wheelchairs in an awkward and inefcient manner. Although there is no direct evidence, epidemiologic or otherwise, linking the wheelchair folding/unfolding task to LBP, the circumstantial evidence cited above led us to

believe that this was a topic that warranted investigation. The purpose of this study was to evaluate this task, in a preliminary and predominantly descriptive way, testing the hypotheses (i) that health-care workers vary greatly in the methods used to fold and unfold manual wheelchairs and (ii) that many of the methods used include bent and twisted back postures that are known to be associated with a high risk of injury.

2. Methods 2.1. Subjects With their informed consent, we studied 20 healthcare workers in a rehabilitation center. Because this was a preliminary descriptive study and the variability of the data was unknown, we chose not to use a power analysis to more formally estimate the sample size. In an effort to achieve a heterogeneous and representative group of health-care workers who routinely deal with wheelchairs, we recruited 5 nurses, 5 health-care aids/porters, 5 occupational therapists and 5 physical therapists. There were 6 men and 14 women and the mean (7SD) age was 32.8 (76.6) years (range 2245). Inclusion criteria included an age range of 1860 years and previous experience folding a wheelchair (at least once during the month prior to the study). We excluded any subject with current or recent LBP, arm pain or any other contraindications to lifting (e.g., uncontrolled

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hypertension or heart disease). Twenty-three people volunteered for the study, but 3 were excluded because they reported current or recent LBP. The study was approved by the Research Ethics Committee of the Queen Elizabeth II Health Sciences Centre. 2.2. Wheelchairs The two wheelchairs (Everest & Jennings, Custom Premier, 4203 Earth City Expressway, Earth City, MO 63045) that we used in this study were representative of those commonly used in both hospital and community settings (Fig. 1) (Deitz and Dudgeon, 1995; Cooper, 1998). The chairs were both cross-braced, folding chairs, each weighing 17.9 kg. They were manually propelled with rear-wheel drive, 60-cm-diameter rear wheels with pneumatic tires, 20-cm-diameter front casters with solid tires, high-mount push-to-lock wheel brakes, removable desk-length armrests, seat rails 48 cm from the oor and swinging, detachable, footrests with heel loops. The two wheelchairs were identical except that one had a sling seat while the other had the seat removed (the no-seat condition). We included both conditions because removable solid seating bases that attach to the seat rails are increasingly being prescribed to improve sitting posture and comfort and, without the sling seat to grasp, the person folding the wheelchair must grasp the seat rails or cross-brace to fold the wheelchair. We chose not to equip the no-seat wheelchair with a drop seat because we wished to focus specically on the folding and unfolding skills. The handling of wheelchair parts (e.g., drop seat, modular backrest, quick-release rear wheels), that sometimes need to be removed to break the wheelchair down into the smallest and lightest components possible for transportation or storage, is sufciently problematic that we considered it beyond the scope of the current study. 2.3. Procedure Subjects were oriented to the experimental setup and completed a brief questionnaire that elicited information on the subjects age, gender and occupation. We also inquired about the subjects experience, training and previous injuries related to the tasks of folding/unfolding a manual cross-braced wheelchair. We positioned the wheelchairs on a smooth tiled surface (commonly found in the health-care setting) with the casters aligned in the rear-trailing position (as though rolling forward). Pilot work had identied that the vertical force (B76 N) needed to fold the wheelchairs varied depending on the oor surface and the alignment of the casters, but we chose to standardize this for the purpose of this preliminary study. The wheelchair was positioned at a 45 angle to a single videocamera located 4 m away from the nearest

rear wheel axle and 1 m above the oor. The videotape data was to ensure that we captured relevant qualitative data, as well as providing data that could be coded and scored. In their starting positions, subjects faced the wheelchair at a 90 angle from the plane of view of the videocamera and behind a line 1.5 m from the right rear wheel axle. A photocell 1.22 m above the oor sensed the motion of the subject moving past the line and triggered a photographic ash within the eld of view of the videocamera. This was for the purpose of timing the tasks, an indirect measure of the subjects task efciency. We asked subjects to fold the wheelchair to its tightest possible position, using their usual methods. Once the subject was satised, he/she stepped back over the starting line. Subjects were permitted to repeat any tasks that they considered unrepresentative of their routine practices. Also, subjects were asked to repeat the task if they forget to step back over the line upon completion of the task. To determine how well the folding task had been completed, we measured the folded width (RESNA, 1998) of the chair (to the nearest mm) using anthropomorphic calipers. We reported the width of the folded wheelchair as a percentage of the unfolded width. We then asked subjects to unfold the chair to its ready to use position, using their usual methods. When the subject had completed these tasks with one wheelchair, he/she repeated the folding and unfolding tasks with the other wheelchair. The order of wheelchairs was randomly assigned. 2.4. Subjective perceptions In addition to the objective evaluations, we considered it important to obtain data on the subjective perceptions of the subjects. After the subjects had completed folding and unfolding both wheelchairs, they used visual analogue scales (VAS) to quantify their perceived exertion and perceived back strain (Ulin et al., 1993). The VAS for the former was labeled not at all difcult or strenuous at 0 mm and extremely difcult and strenuous at 100 mm; the latter was labeled no discomfort or strain experienced at 0 mm and extreme discomfort and strain experienced at 100 mm. We reported the subjects marks on the VASs as percentages of the distance from 0 to 100 mm. The VAS has been found to be a valid and reliable tool for quantifying subjective perceptions (Huskisson et al., 1976; Scott and Huskisson, 1977; Guyatt et al., 1987). Subjects were also asked if they were satised with the methods that they used. 2.5. Data reduction We divided the videotape analysis into components, namely folding and unfolding the footplates of the wheelchair (with the sling seat only, because the

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footplates were identical for the two wheelchairs), folding and unfolding the wheelchair with the sling seat, and folding and unfolding the wheelchair with the sling seat removed. The videotapes were reviewed and coded for the approach (side, rear and/or front), the placement of each hand (on the armrest, push-handle, footplate, seat, seat rail and/or cross-brace), and the most risky back posture observed (as dened by the Ovako Working Posture Analysis System [OWAS])(Karhu et al, 1977; de Bruijn et al., 1998; Li and Buckle, 1999). The OWAS was originally reported by Karhu et al. (1977) and has been used in the study of health-care workers (Engels et al., 1994; Doormaal et al., 1995) and a variety of other settings. Although the OWAS is not a substitute for a detailed biomechanical analysis (Olendorf and Drury, 2001), we considered this tool to be appropriate for a preliminary study such as this one. The OWAS provides a means of classifying arm, leg and back postures. For back postures (the focus of this study), class 1 postures (straight) are those that do not need any special attention, except in special cases, class 2 postures (bent) are those that must be considered during the next regular check of working methods, class 3 postures (twisted) are those that need consideration in the near future and class 4 postures (bent and twisted) are those that need immediate consideration. The times required to complete the tasks of folding and unfolding the two wheelchairs were determined from the videotape, using a frame counter (30 fps). Timing began with the frame in which the photocell triggered the photographic ash and nished when the subject crossed the line at the completion of the task. In the few instances that the ash did not function, the starting time was dened as the frame in which the subjects shoulders passed the photocells. The videorecorder malfunctioned for two subjects, reducing the n values for some measures. 2.6. Statistical analysis We used SAS software (version 6.12, SAS Institute Inc., SAS Campus Drive, Cary, NC 27513) for the statistical analysis. Descriptive statistics were generated. We also compared folding time with unfolding time and the sling-seat vs no-seat conditions using two-way repeated measures ANOVA, after performing a log transformation of the data. Although not the primary purpose of the study, we evaluated the effects that 5 independent measures (age, gender, profession, experience [at least daily vs less frequently] and seat condition [sling seat vs no seat]) had on the 8 outcome (dependent) measures (folding and unfolding times, perceived exertion, perceived back strain, folded width and OWAS scores). We used Spearman correlation analysis to look

at the effect of age, MannWhitney tests to evaluate the effects of gender and experience, Wilcoxon signed-rank tests to look at the effect of seat condition, and Kruskal Willis tests to look at the effect of profession. Because there were 8 dependent measures and we looked at the sling-seat and no-seat conditions separately, we used the Bonferroni procedure to adjust the a level from 0.05 to 0.00313 (0.05/16) to eliminate the effect of multiple comparisons.

3. Results 3.1. Questionnaire Eleven (55%) of the 20 subjects reported completing the task of folding/unfolding a wheelchair at least once a day, with frequencies ranging up to 30 times in a day. The other 9 (45%) subjects reported completing the task with frequencies ranging from 3 to 4 times per week to once a month. In answer to the question about how subjects learned to fold/unfold a wheelchair, of the 27 responses to this question (some subjects included more than one), 12 (44%) responses were self-taught or trialand-error process, 6 (22%) were formal education at physiotherapy or occupational therapy school, 5 (19%) were informal teaching by colleagues, 3 (11%) were taught by an occupational therapist and 1 (4%) was taught by the (hospital) wheelchair coordinator. None of the subjects reported ever having been acutely injured while folding or unfolding a wheelchair. Fourteen (70%) of the subjects reported that their responsibilities included educating community caregivers about folding and unfolding wheelchairs. Sixteen subjects (80%) reported satisfaction with their current methods of folding and unfolding wheelchairs. 3.2. Method variations Subjects used a variety of combinations and permutations of approach, hand placement and back posture7 methods to fold and 9 to unfold the footplates, 7 methods to fold and 14 to unfold the wheelchair with the sling seat, and 10 methods to fold and 7 to unfold the wheelchair with the seat removed. 3.3. Approach directions The side approach was the most common overall, followed by the front approach when folding/unfolding the footplates and the rear approach when folding/ unfolding the wheelchairs themselves. On average, subjects used more than one approach to complete the tasks and one subject used 5.

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3.4. Handholds Of the wheelchair parts used as handholds, the footplates themselves were always grasped when folding/unfolding them; the armrests were the next most commonly used. For folding the wheelchair with the sling seat, the seat was the most common handhold, whereas the armrests and seat rails tied as the most common handholds when unfolding this wheelchair. For both folding and unfolding the wheelchair with no seat, the seat rails were the most commonly used, followed by the armrests. 3.5. Footplates When dealing with the footplates, all but one subject ipped them up to allow folding; the other subject swung them away. The most common method (13 [72%] of 18 subjects when folding the footplates and 15 [83%] when unfolding them) was for the subject to stand beside the wheelchair with one hand on an armrest, then bend over with the back twisted and the legs straight or slightly bent to manipulate the footplates with the other hand. On 5 occasions (28%) while folding the footplates and 1 (6%) while unfolding them, the subjects crouched in front of the wheelchair. On 2 occasions (12%), a foot was used to unfold the footplates. 3.6. Folding the wheelchairs To successfully initiate folding the wheelchair with the sling seat, all 19 subjects grasped the sling seat and lifted (with the hands at both the front and back edges in 17 [90%] and the remaining 2 [10%] with a hand at the front edge only). To complete the folding, 3 subjects (16%) pushed the armrests together and 3 pushed the push-handles together. To initiate folding of the wheelchair with the sling seat removed, 10 (53%) of 19 subjects lifted one or both seat rails. One subject pinched her ngers between the seat rail and clothing guard when folding the chair in this manner. Six other subjects (32%) lifted one or both upper arms of the cross-brace. Seven subjects (37%) completed the fold by squeezing the armrests together, 3 (16%) squeezed the push-handles together and 2 (11%) squeezed the seat rails together. One subject approached the wheelchair from the side, used a hand on a pushhandle to tilt the wheelchair towards him, initiated the fold by pulling on the cross-brace with the other hand and then allowed gravity to complete the fold. 3.7. Unfolding the wheelchairs To initiate unfolding of the wheelchair with the sling seat, 8 (44%) of the 18 subjects pulled the armrests apart, 5 (28%) pulled the push-handles apart (in 2 cases,

the subjects lifted the rear wheels slightly off the ground rst), 3 (17%) pushed down on the seat rails and 2 (11%) pushed on one push-handle and the opposite seat rail or armrest. To complete the unfolding, 9 subjects (50%) pushed down on the sling seat and 4 (22%) pushed down on the seat rails. To initiate unfolding of the wheelchair with the sling seat removed, 9 (47%) of the 19 subjects pulled the armrests apart, 7 (37%) pulled the push-handles apart (in 5 cases, having lifted the rear wheels slightly off the oor), 1 (5%) pushed down on the seat rails and 1 (5%) pushed on one push-handle and the opposite crossbrace. To complete the unfolding, 6 subjects (32%) pushed down on the seat rails and 6 pushed down on the cross-braces. 3.8. Outcome measures These results are summarized in Table 1. The mean OWAS scores were in the 2.43.1 range and 49 (42%) of the 118 scores recorded were class 4. For folding/ unfolding the footrests (not shown in Table 1) (n 18), the mean (7SD) OWAS score was 3.1 (71.1), the median 4 and the range 14. The folding times for the wheelchairs with and without the sling seat were B13 s and the mean unfolding times were in the 915 s range (not signicantly different). The median VAS scores for perceived exertion and back strain were all o15% of the distance from 0100 mm (best to worst). The mean folded widths were o50% of the unfolded widths. 3.9. Effect of independent variables There were no signicant inuences on the outcome (dependent) measures due to the independent measures (age, gender, profession, experience or seat condition), except that subjects required signicantly less time to unfold the wheelchair with the sling seat removed (p 0:00002).

4. Discussion Despite some similarities of approach, the study corroborated the hypotheses that health-care workers vary greatly in the methods used to fold and unfold manual wheelchairs and that many of the methods used include bent and twisted back postures associated with a high risk of injury. The study also yielded interesting descriptive and qualitative information on the methods used. Some participants completed the folding/unfolding tasks as often as 30 times a day. There were a number of ways that participants reported learning how to fold/ unfold a manual wheelchair, but the majority of them reported learning through a trial-and-error process.

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576 H.A. White, R. Lee Kirby / Applied Ergonomics 34 (2003) 571579 Table 1 Folding and unfolding manual wheelchairs by health-care workers Wheelchair with sling seat n Back posture (OWAS)
a

Wheelchair with no seat n 19 Fold Mean 3.0 SD 1.0 Median 3.0 Range 2.04.0 Mean 12.7 SD 4.0 Median 13.0 Range 6.722.4 Mean 13.2 SD 20.1 Median 3.7 Range 069.3 Mean 7.0 SD 12.8 Median 2.9 Range 056.8 Mean 46.8 SD 6.0 Median 45.4 Range 41.464.2 n 19 Unfold Mean 2.6 SD 1.2 Median 2.0 Range 1.04.0 Mean 9.4 SD 3.4 Median 9.2 Range 3.916.6

Fold Mean 2.4 SD 0.8 Median 2.0 Range 2.04.0 Mean 12.9 SD 9.1 Median 9.8 Range 4.645.4 Mean 11.9 SD 14.0 Median 4.2 Range 047.3 Mean 9.1 SD 12.3 Median 4.4 Range 045 Mean 47.5 SD 6.4 Median 45.7 Range 42.871

n 18

Unfold Mean 2.8 SD 1.0 Median 2.0 Range 2.04.0 Mean 14.6 SD 5.3 Median 14.2 Range 4.322.7

19

Time (s)

19

18

19

19

Perceived exertion (%)b

20

20

Perceived back strain (%)b

20

20

Folded width (%)c

20

20

Ovako Working Posture Analysis System (OWAS) scores (14). Percentage of distance from 0 to 100 mm (from best to worst) on a visual analog scale. c Percentage of unfolded width.
b

Ideally, the operation of a well-designed product should be intuitive and self-evident. When good design is insufcient to ensure safe operation, as seems to have been the case for the wheelchair designs that we studied, one complementary approach would be more formal ergonomics training about the task during professional education (Engels et al., 1998; Johnsson et al., 2002). None of the participants reported learning from an owners manual for a wheelchair. Given that such manuals are easily misplaced by users and that healthcare professionals may not see the manuals, better labeling of the wheelchair with instructions may be a more effective approach. Given our small sample size, it was not surprising that none of the study participants had been acutely injured during the task of folding or unfolding a wheelchair. This could have been because the incidence of such injuries is low. Alternatively, given that the magnitudes of perceived exertion and back strain that our subjects reported were low, any risk of LBP that they incurred due to the folding/unfolding tasks could be due to cumulative trauma. Although the etiology of LBP remains unclear in many cases, one theory is that LBP is the cumulative effect of a number of minor painless injuries which eventually result in pain (Biering-

Sorensen, 1983; Garg and Moore, 1992; Knibbe and Friele, 1996; Hignett, 1996; Daynard et al., 2001). Biering-Sorensen (1983), for instance, found that about half of the people surveyed reported a gradual onset of LBP. It is therefore conceivable (but, by no means, proven) that improperly folding or unfolding a wheelchair could contribute to the development of LBP. The OWAS scores were in the moderate-to-high range, suggesting the need to explore different wheelchair designs (as noted earlier) or alternate methods for folding and unfolding wheelchairs that carry with them a lower risk of back injury. We are optimistic about the success of the latter because we observed examples of methods that appeared to be both safe and effective. To minimize the risk of back injury, the most ergonomically sound method (by which we mean the method that minimized bent and twisted back postures (Karhu et al., 1977)) that we observed for folding and unfolding the footplates was the crouch method (Fig. 2). This method was used by 5 subjects in our study to fold the footplates and 1 to unfold them. In the crouch method, the subject approaches the chair from the front or side, rests one hand on the armrest or seat for balance, does a complete knee bend and uses the other hand to manipulate the footplates to the upright

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Fig. 2. Folding and unfolding footplates with the crouch method.

Fig. 4. Unfolding a wheelchair with the rear-lift method.

Fig. 3. Folding a wheelchair with the side-tip method.

position. With this method, there is no need to bend or twist the back (i.e., an OWAS score of 1). Although safer, this method requires more time and energy than the bending-over method. To fold the wheelchair, the side-tip method (Fig. 3) appeared to be the most ergonomically sound. None of

the subjects used this method for folding the wheelchair with the sling seat but one subject used this method for folding the wheelchair with the sling seat removed. In the side-tip method, the subject approaches the chair from the side. The subject places the rear hand on the near-side push-handle, bends straight forward and places the front hand on either the front edge of the sling seat or, if the sling seat has been removed, on the near-side seat rail. Although the subject must bend forward (i.e., an OWAS score of 2), the method does not require the subject to twist the back. The subject then tilts the wheelchair towards him/herself. This eliminates the frictional force (that resists wheelchair folding) between the far-side rear wheel and the oor. Once the far-side wheels are off the ground, pulling upwards on the sling upholstery or the seat rail initiates the fold and gravity completes it. If the seat rail is used as a handhold, the ngers should be removed quickly to prevent pinching, but a folding strap would obviate this risk. Once the wheelchair is completely folded, the user tilts the chair back so that all wheels rest on the oor. The most ergonomically sound method that we observed for unfolding a wheelchair was the rearlift method (Fig. 4). Two subjects for the sling-seat

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wheelchair and 5 subjects for the no-seat wheelchair used this method. In the rear-lift method, the subject approaches the chair from the rear, grasps the pushhandles, lifts the rear wheels slightly off the oor and pulls the push-handles apart. Lifting the rear wheels enables the user to eliminate the frictional force between the oor and rear wheels. The caster wheels swivel and then roll in response to the frictional forces affecting them. The user need not bend or twist the back (i.e., an OWAS score of 1). However, wheelchairs with seat-rail clips or sticky cross-brace articulations require the subject to lean straight forward with one hand on a push-handle for balance and to use the other hand to exert a downward force on the seat rails (i.e., an OWAS score of 2). Although the methods described above are promising, further testing will be needed to determine whether they are effective, efcient and decrease the risk of injury associated with wheelchair handling. Other limitations of the study include the small sample size studied. The general lack of inuence of age, gender, profession, experience and seat condition on the outcome measures may have been due to the small sample size. Other limitations include the single wheelchair design studied, the use of the OWAS rather than a more detailed biomechanical analysis, studying the narrowly dened task that we did (rather than including related tasks, like the removal of drop seats, modular backrests and rear wheels), conning the study condition to a single oor surface, and limiting our study population to health-care professionals (whereas hospital volunteers and nonprofessional caregivers are also frequently called upon to fold and unfold wheelchairs). Despite these caveats and the need for further study, this is the rst study to provide data about the methods used by health-care workers to fold and unfold manual wheelchairs.

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5. Conclusion Health-care workers use a variety of methods to fold and unfold wheelchairs, many of which include bent and twisted back postures that may carry a risk of injury. Further study is needed to conrm this risk, to identify more ergonomically sound wheelchair designs and to develop better methods of carrying out the common and important task of folding and unfolding wheelchairs.

Acknowledgements We thank Dr. John McCabe, Dr. John Kozey, Dr. Biman Das, Mr. Don MacLeod, Mr. Wade Blanchard and Mr. Darrin Smith for their help.

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