www.fisiokinesiterapia.biz Management of Shoulder Pain in Persons with SCI
Research Program Development from a Clinical Perspective Identification of the problem Identification of potential cause Development of treatment program
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
Shoulder Pain with SCI % 100 80 60 40 20 Tetra Para 0 Sie et al., 1992 < 5 5-9 10-14 15-19 > 20 Years since onset
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
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
Rotator Cuff Tendinopathy Rat shoulder model Trauma combined with Overuse Greater tendon thickness Reduced load to failure 2.5 2 1.5 1 0.5 0 Tendon Thickness Trauma Overuse Tr + Ov Load to Failure Soslowsky et al., 2002
Functional Demands Associated with Shoulder Pain in SCI Manual WC Propulsion Pressure Relief Raise Depression Transfers Overhead Activities
Demands of Manual WC Propulsion Highly repetitive Weight bearing Bilateral
Shoulder Motion Initial contact with humerus in extension, abduction & internal rotation Loading mechanics create potential for impingement Newsam et al., 1999
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., 1998 40 20 0 posterior superior 0 20 40 60 80 100 % PUSH
PUSH Phase Muscles Mulroy et al., 1996
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
RECOVERY Phase Muscles Mulroy et al., 1996
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
Demands of Depression Transfers & Raises High Superior shoulder forces 50% of body weight High muscle intensity with prolonged duration Low repetition
Depression Transfers & Raises Latissimus Dorsi & Pectoralis Major elevate trunk & protect G-H joint Reyes et al., 1995 Perry et al., 1996
Depression Transfers & Raises Weakness or fatigue threatens G-H joint integrity
Depression Transfer LOW Paraplegia 100 80 LEAD TRAIL N = 12 % MMT 60 40 20 0 Supra Infra Subscap Perry et al., 1996
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
STOMPS Protocol Design Global Clinical Program Recruitment Screening & Pre-assessment Randomized Homogenous population Attention Control Exercise/Optimization Education Post assessment
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
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
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
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
Exercise & Movement Optimization Program 12wks Stretching Shoulder / Rotator Cuff Strengthening Training / Instruction in Movement Performance WC Propulsion Transfers & Raises
Standardized Stretching Program Anterior Thoracic Posterior Capsule Upper Trapezius
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
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)
Hypertrophy Exercise 8RM Diagonal pull-downs Pectoralis major Propulsion power Active in transfers Non-weight bearing
Hypertrophy Exercise 8RM External rotation Infraspinatus PUSH phase of WC propulsion Active in transfers
Endurance Exercise 15RM Scaption Supraspinatus Active in both PUSH & RECOVERY phase of WC propulsion
Endurance Exercise 15RM Scapular Retraction Rhomboids RECOVERY phase of WC propulsion at 62% PC duration
Movement Optimization Transfers Modify height of transfer surface Hand & arm position WC Propulsion Propulsion technique Energy conservation