Management of Shoulder Pain in Persons with SCI

Transcription

1 Management of Shoulder Pain in Persons with SCI

2 Research Program Development from a Clinical Perspective Identification of the problem Identification of potential cause Development of treatment program

3 Living with SCI Life expectancy approaches that of non-disabled population 20 y.o. non-disabled = 58 additional years 20 y.o. with paraplegia = 46 additional years 20 y.o. with tetraplegia = 42 additional years 40% of people with SCI are over age 46 National SCI Database

4 Shoulder Pain with SCI % Tetra Para 0 Sie et al., 1992 < > 20 Years since onset

5 Shoulder Pathology in SCI The most common causes of shoulder pain in persons with chronic SCI are musculoskeletal, particularly overuse injuries to the rotator cuff. Impingement syndrome Rotator cuff tendinitis Supraspinatus tendinitis Bicipital tendinitis Subacromial bursitis Dyson-Hudson & Kirshblum, 2004

6 The Weight-Bearing Shoulder Shoulder designed for locating the hand in the environment Weight-bearing tasks transfer forces to shoulder via the humerus Significant risk for impingement of subacromial structures

7 Rotator Cuff Tendinopathy Rat shoulder model Trauma combined with Overuse Greater tendon thickness Reduced load to failure Tendon Thickness Trauma Overuse Tr + Ov Load to Failure Soslowsky et al., 2002

8 Functional Demands Associated with Shoulder Pain in SCI Manual WC Propulsion Pressure Relief Raise Depression Transfers Overhead Activities

9 Demands of Manual WC Propulsion Highly repetitive Weight bearing Bilateral

10 Shoulder Motion Initial contact with humerus in extension, abduction & internal rotation Loading mechanics create potential for impingement Newsam et al., 1999

11 Shoulder Joint Reaction Forces Predominantly superior and posterior during push phase -20 Superior force increases > 3-fold -40 during FAST and -60 GRADED propulsion Kulig et al., posterior superior % PUSH

12 PUSH Phase Muscles Mulroy et al., 1996

13 PUSH Phase Muscles Generate propulsion force & protect G-H joint Humeral Flexors Pectoralis Major & Anterior Deltoid Rotator Cuff Infraspinatus & Supraspinatus Scapular Muscles Serratus Anterior Mulroy et al., 1996

14 RECOVERY Phase Muscles Mulroy et al., 1996

15 RECOVERY Phase Muscles Decelerate arm & reposition hand Humeral Elevators Middle & Posterior Deltoid Rotator Cuff Subscapularis & Supraspinatus Scapular Muscles Middle Trapezius (Rhomboid) Mulroy et al., 1996

16 Demands of Depression Transfers & Raises High Superior shoulder forces 50% of body weight High muscle intensity with prolonged duration Low repetition

17 Depression Transfers & Raises Latissimus Dorsi & Pectoralis Major elevate trunk & protect G-H joint Reyes et al., 1995 Perry et al., 1996

18 Depression Transfers & Raises Weakness or fatigue threatens G-H joint integrity

19 Depression Transfer LOW Paraplegia LEAD TRAIL N = 12 % MMT Supra Infra Subscap Perry et al., 1996

20 Risk Factors for Shoulder Pain in SCI Modifiable Posture ROM Body Mass Muscle strength SHOULDER PAIN Non-Modifiable Age Duration of SCI Anatomy UE Trauma Functional Demands Functional Demands

21 STOMPS Protocol Design Global Clinical Program Recruitment Screening & Pre-assessment Randomized Homogenous population Attention Control Exercise/Optimization Education Post assessment

22 Enrollment Criteria INCLUSION Paraplegia from SCI Shoulder pain Propel manual WC > 50% 5 years post onset of SCI EXCLUSION Steroid injection in past 4 months Surgery in past year RA, CRPS, Adhesive capsulitis Complete RC tear

23 Recruitment Challenges Redefining PAIN for the person with chronic SCI What is EXERCISE as it relates to shoulder pain? Not just any UE weight training Mobility is not exercise Previous therapy experiences

24 Education Program 12wks 1-hr educational video on shoulder care with handout APTA shoulder education pamphlets Question & Answer session Keep log to record any changes that affect shoulder pain

25 Standardized and Individualized Intervention Protocol Standardized Content Relative exercise intensity Individualized Exercise modification if needed for balance, elbow & wrist pain Method of transfer / WC propulsion style

26 Exercise & Movement Optimization Program 12wks Stretching Shoulder / Rotator Cuff Strengthening Training / Instruction in Movement Performance WC Propulsion Transfers & Raises

27 Standardized Stretching Program Anterior Thoracic Posterior Capsule Upper Trapezius

28 Standardized Strengthening Program Home Exercise Program 3 days per week DuraBand elastic bands & free weights Performed from a wheelchair Based on guidelines for hypertrophy and endurance from ACSM & NSCA

29 Standardized Strengthening Program Program Goals Shoulder pain vs. visible muscle mass 2 hypertrophy exercises (3 sets of 8 reps) 2 endurance exercises (3 sets of 15 reps)

30 Hypertrophy Exercise 8RM Diagonal pull-downs Pectoralis major Propulsion power Active in transfers Non-weight bearing

31 Hypertrophy Exercise 8RM External rotation Infraspinatus PUSH phase of WC propulsion Active in transfers

32 Endurance Exercise 15RM Scaption Supraspinatus Active in both PUSH & RECOVERY phase of WC propulsion

33 Endurance Exercise 15RM Scapular Retraction Rhomboids RECOVERY phase of WC propulsion at 62% PC duration

34 Movement Optimization Transfers Modify height of transfer surface Hand & arm position WC Propulsion Propulsion technique Energy conservation