Craig J. Newsam, D.P.T. Pathokinesiology Laboratory Rancho Los Amigos National Rehabilitation Center

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

4. 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

5. Shoulder Pain with SCI Paralysis of the lower extremities from SCI increases the demand on the upper extremities for daily function and mobility The prevalence of Upper extremity pain and dysfunction is significantly greater than normal in the SCI population – a situation identified by Rancho’s model systems that worsens with increasing time since injury affecting over 70% of individuals by 20 years post injury. Rotator cuff tendonitis and tears are the most common diagnosis see in patients with SCI presenting with shoulder pain This increase in shoulder dysfunction has been attributed to repetitive weight-bearing activities imposed by SCI Paralysis of the lower extremities from SCI increases the demand on the upper extremities for daily function and mobility The prevalence of Upper extremity pain and dysfunction is significantly greater than normal in the SCI population – a situation identified by Rancho’s model systems that worsens with increasing time since injury affecting over 70% of individuals by 20 years post injury. Rotator cuff tendonitis and tears are the most common diagnosis see in patients with SCI presenting with shoulder pain This increase in shoulder dysfunction has been attributed to repetitive weight-bearing activities imposed by SCI

6. Shoulder Pathology in SCI

7. The Weight-Bearing Shoulder Shoulder designed for locating the hand in the environment Paralysis of the lower extremities from SCI increases the demand on the upper extremities for daily function and mobility The prevalence of Upper extremity pain and dysfunction is significantly greater than normal in the SCI population – a situation identified by Rancho’s model systems that worsens with increasing time since injury affecting over 70% of individuals by 20 years post injury. Rotator cuff tendonitis and tears are the most common diagnosis see in patients with SCI presenting with shoulder pain This increase in shoulder dysfunction has been attributed to repetitive weight-bearing activities imposed by SCI Paralysis of the lower extremities from SCI increases the demand on the upper extremities for daily function and mobility The prevalence of Upper extremity pain and dysfunction is significantly greater than normal in the SCI population – a situation identified by Rancho’s model systems that worsens with increasing time since injury affecting over 70% of individuals by 20 years post injury. Rotator cuff tendonitis and tears are the most common diagnosis see in patients with SCI presenting with shoulder pain This increase in shoulder dysfunction has been attributed to repetitive weight-bearing activities imposed by SCI

8. Rat shoulder model Trauma combined with Overuse Greater tendon thickness Reduced load to failure Paralysis of the lower extremities from SCI increases the demand on the upper extremities for daily function and mobility The prevalence of Upper extremity pain and dysfunction is significantly greater than normal in the SCI population – a situation identified by Rancho’s model systems that worsens with increasing time since injury affecting over 70% of individuals by 20 years post injury. Rotator cuff tendonitis and tears are the most common diagnosis see in patients with SCI presenting with shoulder pain This increase in shoulder dysfunction has been attributed to repetitive weight-bearing activities imposed by SCI Paralysis of the lower extremities from SCI increases the demand on the upper extremities for daily function and mobility The prevalence of Upper extremity pain and dysfunction is significantly greater than normal in the SCI population – a situation identified by Rancho’s model systems that worsens with increasing time since injury affecting over 70% of individuals by 20 years post injury. Rotator cuff tendonitis and tears are the most common diagnosis see in patients with SCI presenting with shoulder pain This increase in shoulder dysfunction has been attributed to repetitive weight-bearing activities imposed by SCI

10. Demands of Manual WC Propulsion Highly repetitive Weight bearing Bilateral WC propulsion has been identified as a major culprit in shoulder pain because it is a highly repetitive weight-bearing activity. Its bilateral nature makes it difficult to rest a painful shoulder. WC propulsion has been identified as a major culprit in shoulder pain because it is a highly repetitive weight-bearing activity. Its bilateral nature makes it difficult to rest a painful shoulder.

11. Shoulder Motion Initial contact with humerus in extension, abduction & internal rotation Loading mechanics create potential for impingement

12. Shoulder Joint Reaction Forces Predominantly superior and posterior during push phase Superior force increases > 3-fold during FAST and GRADED propulsion For individuals with paraplegia and fully functioning upper extremities, the shoulder joint reaction force during the push phase of WCP was predominantly superiorly and posteriorly directed. The peak superior force at the shoulder was partially off-set by the weight of the arm resulting in low to moderate force in free propulsion. For individuals with paraplegia and fully functioning upper extremities, the shoulder joint reaction force during the push phase of WCP was predominantly superiorly and posteriorly directed. The peak superior force at the shoulder was partially off-set by the weight of the arm resulting in low to moderate force in free propulsion.

14. PUSH Phase Muscles Generate propulsion force & protect G-H joint Humeral Flexors Pectoralis Major & Anterior Deltoid Rotator Cuff Infraspinatus & Supraspinatus Scapular Muscles Serratus Anterior

16. RECOVERY Phase Muscles Decelerate arm & reposition hand Humeral Elevators Middle & Posterior Deltoid Rotator Cuff Subscapularis & Supraspinatus Scapular Muscles Middle Trapezius (Rhomboid)

17. Demands of Depression Transfers & Raises High Superior shoulder forces – 50% of body weight High muscle intensity with prolonged duration Low repetition Despite a slower velocity, the superior forces at the shoulder during WCP were similar for subjects with C6 tetraplegia and Increased for those with C7 level injuries. Subjects with tetraplegia have a slower propulsion velocity but require longer duration of muscle activity to propel the chair. They generate similar or even larger superior joint forces with less protective muscle support Despite a slower velocity, the superior forces at the shoulder during WCP were similar for subjects with C6 tetraplegia and Increased for those with C7 level injuries. Subjects with tetraplegia have a slower propulsion velocity but require longer duration of muscle activity to propel the chair. They generate similar or even larger superior joint forces with less protective muscle support

20. Depression Transfer – LOW Paraplegia

21. Risk Factors for Shoulder Pain in SCI

22. STOMPS Protocol Design

23. Enrollment Criteria INCLUSION Paraplegia from SCI Shoulder pain Propel manual WC > 50% 5 years post onset of SCI

24. 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

25. 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

26. Standardized and Individualized Intervention Protocol

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

28. Standardized Stretching Program

29. Standardized Strengthening Program

30. Standardized Strengthening Program

31. Hypertrophy Exercise – 8RM Diagonal pull-downs

32. Hypertrophy Exercise – 8RM External rotation

33. Endurance Exercise – 15RM Scaption

34. Endurance Exercise – 15RM Scapular Retraction

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