Aging
with Spinal Cord Injury
by
Lilli Thompson, PT
What
is the Shoulder Pain Problem?
Prevention
and Treatment
Common Causes of Shoulder Pain
Treatment Considerations for Shoulder
Pain
Recommended exercises to learn from your health
care provider
What is the Shoulder Pain Problem?
Because people with disabling impairments live longer, more active lives, there has been a dramatic increase in the number of people who use a wheelchair or mobility-assisting device for 20, 30 even 40 years. The downside of this prolonged wheelchair use is the increased risk of developing upper extremity pain. Overuse or altered use of the arms, combined with aging and other physical factors creates conditions that increase the chances of experiencing painful upper extremities. While any of the upper extremity joints may be affected, the shoulder region is frequently reported as painful by persons with a spinal cord injury (SCI).
Shoulder pain in individuals with SCI has been identified as a common and persistent problem. Recent research indicates as many as 30 % to 50 % of the SCI population has new or chronic shoulder pain. People with SCI have specific factors that contribute to the increased risk. These factors include the duration of the injury and the age of the individual. Some people develop shoulder pain right after injury, during early rehabilitation. The pain can persist and become a chronic condition. This early onset shoulder pain is probably due to weakness or paralysis of the muscles that stabilize the shoulder joint, abnormal patterns of shoulder movements created by cervical stabilizing devices, the round shouldered posture used to achieve sitting balance and the intense and unusual demands suddenly placed on the shoulder muscles and joints in individuals who are newly paralyzed. Once a painful shoulder condition becomes chronic, it is much harder to treat and resolve. Therefore, aggressive protection and treatment of individuals' shoulders during early rehabilitation is critical to prevent the development of shoulder pain and to quickly and effectively alleviate any new symptoms of pain.
People who have been living with a SCI for years have a greater risk of developing shoulder problems, and the pain can have a significant impact on functional activities. It is also known that the shoulder is a common site for degenerative changes due to aging in the general population. The muscles and tendons that make up the rotator cuff complex are particularly susceptible to degenerative changes because of how the shoulder joint is designed. The tendons of the rotator cuff are easily pinched or impinged under the bony arch of the shoulder blade when the arm is raised overhead or when the arm is required to bear weight. Repeated impingement of the rotator cuff tendons can cause chronic swelling (inflammation or tendonitis), tears in the tendons and pain. Some common signs of degeneration of the shoulder are tendonitis of the rotator cuff and/or biceps tendons, bursitis (inflammation of the fluid-filled sac that protects the shoulder joint) and frozen shoulder (known as adhesive capsulitis).
Use of a wheelchair or assistive device for mobility creates an even greater risk of impingement. For example, sitting with a kyphotic posture and rounded-shoulders, in an attempt to maintain balance when performing daily activities, can dramatically increase the risk of impingement. The frequent need to reach overhead when functioning from a seated position and the increased demand on the shoulder when pushing a wheelchair contribute to the higher risk. Performing transfers, raises and walking with a cane or walker also create a risk of impingement if the muscles that stabilize the shoulder are not sufficiently strong. All of these conditions cause pain and limit the use of the shoulder and arm even in people without a disability. The functional impact of shoulder pain can be quite significant in people who rely on their arms for mobility. Bed mobility, transfers, sleeping, dressing, wheelchair propulsion and/or walking with assistive aids can all be detrimentally affected. As a result, full participation in critical activities such as work, school, family and community activities can be limited.
Some of the problems that increase the risk of shoulder pain can be prevented. For instance, adjusting a person's wheelchair position and seating posture can provide adequate sitting balance and support to prevent the need to sit with a round shouldered posture. Other factors that contribute to shoulder pain in persons with SCI have to be accommodated. For example, using the arms for transfers or pushing the wheelchair is usually a necessity, but strengthening key muscles of the shoulders can better protect the joints during these activities. In some cases, painful conditions develop despite taking care to prevent and protect the shoulders. When this happens, the critical issue is to seek prompt treatment and consider how to modify any painful activities. Changing the techniques to accomplish daily tasks, such as using a slide board for transfers or a powered wheelchair for community mobility, may allow some activities to continue during the healing phase or to preserve long-term function.
It is important that persons with SCI work closely with their health care providers to prevent and treat shoulder problems. The health care provider needs to fully understand how the shoulders are used for daily function and the patient should communicate how the problem and proposed treatment options will impact function. Conventional treatment for shoulder conditions may be highly effective and should be considered by the health care provider. Treatment interventions must usually go beyond simple conventional symptom management and address movement strategies and function due to the more complex mobility needs of persons with SCI. The important issues to remember are to NOT delay seeking medical attention and to stress the importance of prompt effective treatment.
Common Causes of Shoulder Pain
- Poor sitting posture--round shoulders, head forward, kyphosis of the thoracic spine, sacral sitting, scoliosis
- Weak muscles that stabilize the shoulder blade and rotate the arm outward compared to the other shoulder muscles (i.e. weak external arm rotators and strong deltoids)
- New weakness or weakness of other muscles of the arms
- Trauma or injury (such as falling onto an outstretched arm, tearing tendons, brachial plexus injury, fracture)
- Excessive weight bearing on the arms, especially when muscles are fatigued (Leaning heavily on an assistive device, numerous transfers and/or long term wheelchair pushing with arm fatigue)
- Poor or less than optimal transfer and/or wheelchair pushing techniques
- Excessive weight gain
- Sleep positioning directly on the shoulder
- Cervical spine or neck problems
Treatment Considerations for Shoulder Pain
- Seek treatment for the symptoms and cause of the pain as soon as possible (do not delay, hoping that the problem will just go away by itself). Treatment is usually more effective when started earlier than when delayed.
- Your health care provider should identify any further testing necessary and discuss the treatment options that are right for you and your condition.
- Discuss how these options will work for you and your particular disability and functional needs with your health care provider. Be sure to talk about any problems or concerns you have about the recommended treatments, problem-solve solutions with your provider and clarify the plan of action.
- Common treatment options include the use of modalities, therapeutic exercises, medication, biofeedback, relaxation techniques, modification of activities and/or equipment, injections, surgery or other forms of treatment.
- Take a good look at your equipment and how you perform activities--consider how to improve efficiency, streamline activities and make activities as pain-free as possible. Consider if using a different technique or different equipment would help resolve or prevent shoulder pain. Try to implement these changes on a daily basis.
- Obtain adequate sitting support to maintain an upright posture when performing activities that involve use of the arms (especially reaching upward, forward or outward) If necessary, readjust posture to sit upright for those activities.
- Perform daily stretching and strengthening exercises on certain key muscles of the shoulder (see exercises described below)
- Rest your arms when they become fatigued--do not continue walking or pushing when muscles feel overly tired. Stop and take a short rest break to let your arms recover. You may need to take more frequent breaks for longer distances or if your arms become shaky or sore.
- Maintain your equipment in optimal condition to preserve mobility efficiency and avoid accidents and/or injury.
- Take charge and clearly instruct others when they attempt to help you with mobility issues (e.g., if you have fallen and someone attempts to help you up, with transfers, bed mobility or with community wheelchair mobility)
- Promptly investigate any new loss of sensation or muscle strength that occurs in your arms or hands.
Recommended exercises to learn from your health care provider
(Using a light resistive exercise band)
- External and internal rotator strengthening
- Adductor strengthening
- Scapular retractor strengthening
- Pectoral stretch (with external arm rotation)
- Biceps stretch (both long and short head)
Published
by the Rehabilitation Research and Training Center on Aging with A Disability,
Rancho Los Amigos National Rehabilitation Center, Downey, CA. Supported
by a grant from the National Institute on Disability and Rehabilitation
Research, Office of Special Education and Rehabilitative Services, U.S.
Dept. of Education, #H133B980024
Rehabilitation
Research and Training Center on Aging with a Disability
Rancho Los Amigos National Rehabilitation Center
7601 E. Imperial Hwy, Building 800-W
Downey, California 90242; (voice) 562-401-7402; (fax) 562-401-7011
webmaster: chuck.sanders@agingwithdisability.org
last updated 11/14/2006
