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Shoulder Pain in Patients with Spinal Cord Injury

Shoulder Pain in Patients with Spinal Cord Injury. Exercise and Activity Modification for Reducing Pain Abby Osborn, SPT UNC June 17, 2013. Objectives. Review shoulder impingement. Increase knowledge of best-evidenced shoulder exercises for decreased pain in manual wheelchair users.

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Shoulder Pain in Patients with Spinal Cord Injury

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  1. Shoulder Pain in Patients with Spinal Cord Injury Exercise and Activity Modification for Reducing Pain Abby Osborn, SPT UNC June 17, 2013

  2. Objectives • Review shoulder impingement. • Increase knowledge of best-evidenced shoulder exercises for decreased pain in manual wheelchair users.

  3. Statistics1 • Prevalence: 30-60% of persons with SCI develop shoulder pain. • Shoulder is most common location of pain post SCI. • Most common etiologies: chronic impingement syndromes (75%) and rotator cuff tears (65-71%). • Shoulder pain leads to decreased physical activity and decreased QOL.

  4. Impingement2,3,4 • ↓ Subacromial space • Muscle contributions: • Poor RC function • Poor scapular stabilizer function • ↑ Upper trapezius, • ↓ Serratus Anterior • Tight pectoralis minor and posterior capsule • Kinematic activity with shoulder elevation: • ↑ superior & anterior translation of humeral head on glenoid • ↓ humerus external rotation • Scapula: ↓ posterior tilting, ↓upward rotation

  5. Treatment Options • Rest • Pain management • Modalities: FES, Taping • Exercise • Surgery • In an orthopedic population, evidence suggests exercise is equally as effective as surgery. 5,6,7,8 • Can this translate to SCI (and W/C users) despite repetitive UE weight bearing activities and decreased ability to rest and protect shoulders?

  6. Outcome Measure: WUSPI9 • MDC: 5.1 points • MCID: n/a • Scale: 0-150 • (-) self-report Nawoczenski D A et al. PHYS THER 2006;86:1604-1618

  7. Nawoczenski4 et al 2006 • “Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Cord Injury” • Home-based stretching and strengthening program • 8 weeks • Scapular focused + GH ER’s • EMG isolated muscles for instruction of exercises

  8. Nawoczenski 2006

  9. Nawoczenski 2006

  10. Mulroy1 et al 2011 • “Strengthening and Optimal Movements for painful shoulders (STOMPS) in Chronic Spinal Cord Injury: A RCT” • 12 week home-based exercise program – stretching, warm-up, strengthening • Activity Modification component

  11. Mulroy 2011 Mulroy S J et al. PHYS THER 2011;91:305-324

  12. Mulroy 2011

  13. Mulroy 2011

  14. Results Mulroy 2011

  15. Research Says: • (+): A skillfully structured exercise program appears decrease shoulder pain in SCI patients. • (-): The patients in these studies had chronic (>3 month) shoulder pain and had acquired their injury >1 year ago (mean of 17 and 18 years ago). • Does not capture shoulder pain outside of impingement cause such as trauma, hemiplegia, and denervation. • Does not account for acute injuries. • (+) If we start appropriate patients on shoulder HEP’s in rehab, there is possibility to decrease future development of pain and disability!!!

  16. Wait, there’s more!

  17. Reinold10 et al 2009 • “Current Concepts in the Scientific and Clinical Rationale Behind Exercises for Glenohumeral and Scapulothoracic Musculature.” • “[F]ew studies have been conducted to determine the efficacy of specific shoulder rehabilitation exercises. Thus, knowledge of anatomy, biomechanics, and function of specific musculature is critical in an attempt to develop the most advantageous rehabilitation programs.” • Hold scapular retraction posture throughout!

  18. Reinold 2009 Rotator Cuff • Supraspinatus (Abd) • Full can • Infraspinatus & Teres Minor (ER) • Sidelying ER, ER at 45 Abd, Prone ER at 90 • Subscapularis (IR) • Push-up plus, Diagonal Ref. 11,12,13.

  19. Scapulothoracic Mm Reinold 2009 • Serratus Anterior* 3D • Push-up plus, Dynamic hug • Anterior punch at 120 degrees Abd • Lower Trapezius* *want high LT:UT • Bilateral ER at 0 degrees Abd • Sidelying ER, Prone horiz Abd at 90 + ER Ref. 14, 13, 15, 16.

  20. Reinold 2009

  21. Questions?

  22. References 1. Mulroy S. J., Thompson L., Kemp B., Hatchett P., Newsam C. J., Gutierrez D. D., Ge T., Haubert L. L., Eberly V. J., Azen S., Winstein C. J., Gordon J., Physical Therapy Clinical Research Network, (PTClinResNet) (2011a). Strengthening and optimal movements for painful shoulders (STOMPS) in chronic spinal cord injury: a randomized, controlled trial. Phys. Ther.91, 305–324. doi: 10.2522/ptj.20100182. 2.. Graichen H, Bonel H, Stammberger T, et al. Threedimensional analysis of the width of the subacromial space in healthy subjects and patients with impingement syndrome. AJR Am J Roentgenol. 1999;172:1081-1086. 3. Ludewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther. 2000;80:276-291. 4. Nawoczenski DA, Ritter-Soronen JM, Wilson CM, et al. Clinical trial of exercise for shoulder pain in chronic spinal injury. Phys Ther. 2006;86:1604–1618. 5. Haahr JP, Ostergaard S, Dalsgaard J, et al. Exercises versus arthroscopic decompression in patients with subacromial impingement: a randomised, controlled study in 90 cases with a one-year follow-up. Ann Rheum Dis. 2005;64:760–764. 6. Haahr JP, Anderson JH. Exercises may be as efficient as subacromial decompression in patients with subacromial stage II impingement: 4–8 years’ follow-up in a prospective, randomized study. Scand J Rheumatol. 2006;35:224–228. 7. Brox JI, Staff PH, Ljunggren AE, Brevik JI. Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome) [erratum in:BMJ. 1993;307:1269]. BMJ. 1993;307:899–903.

  23. References cont. 8. Brox JI, Gjengedal E, Uppheim G, et al. Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II impingement syndrome): a prospective, randomized, controlled study in 125 patients with a 2 1/2 year followup. J Shoulder Elbow Surg. 1999;8: 102–111. 9. Rehabmeasures.org. Accessed on June 15, 2013. 10. Reinold MM, Escamilla RF, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. J Orthop Sports Phys Ther. 2009 Feb;39(2):105-17. doi: 10.2519/jospt.2009.2835. 11. Reinold MM, Macrina LC, Wilk KE, et al. Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises. J Athl Train. 2007;42:464-469. 12. Reinold MM, Wilk KE, Fleisig GS, et al. Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises. J Orthop Sports Phys Ther. 2004;34:385-394. http://dx.doi. org/10.2519/jospt.2004.0665 13. Decker MJ, Tokish JM, Ellis HB, Torry MR, Hawkins RJ. Subscapularis muscle activity during selected rehabilitation exercises. Am J Sports Med. 2003;31:126-134. 14. Ekstrom RA, Donatelli RA, Soderberg GL. Surface electromyographic analysis of exercises for the trapezius and serratus anterior muscles. J Orthop Sports Phys Ther. 2003;33:247-258. 15. Cools AM, Dewitte V, Lanszweert F, et al. Rehabilitation of scapular muscle balance: which exercises to prescribe? Am J Sports Med. 2007;35:1744-1751. http://dx.doi. org/10.1177/0363546507303560 16. McCabe RA. Surface electromyographic analysis of the lower trapezius muscle during exercises performed below ninety degrees of shoulder elevation in healthy subjects. N Am J Sports Phys Ther. 2007;2:34-43.

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