Aging with Spinal Cord Injury: Changing Mobility Needs

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Development of a Standardized and Individualized
Intervention Protocol for the STOMPS Project
Management of Shoulder Pain in Persons with SCI
Craig J. Newsam, D.P.T. Pathokinesiology
Laboratory Rancho Los Amigos National
Rehabilitation Center
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LEAD INVESTIGATORS Sara Mulroy, PhD, PT
Bryan Kemp, PhD Pathokinesiology Lab
Center for Aging with Disability RLANRC
RLANRC
PROJECT COORDINATOR Dee Gutierrez, PT
Assessment Dee Gutierrez, PT Lisa Lighthall
Haubert, PT Valerie Eberly, PT
Intervention Craig Newsam, PT Jennifer Whitney, PT
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Research Program Development from a Clinical
Perspective

• Identification of the problem
• Identification of potential cause
• Development of treatment program

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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 www.spinalcord.uab.edu 2004
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Shoulder Pain with SCI

20
Years since onset
Sie et al., 1992
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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
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The Weight-Bearing Shoulder

• Shoulder designed for locating the hand in the
  environment

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Rotator Cuff Tendinopathy

• Rat shoulder model
• Trauma combined with Overuse
• Greater tendon thickness
• Reduced load to failure

Soslowsky et al., 2002
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Functional Demands Associated with Shoulder Pain
in SCI

• Manual WC Propulsion
• Pressure Relief Raise
• Depression Transfers
• Overhead Activities

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Demands of Manual WC Propulsion

• Highly repetitive
• Weight bearing
• Bilateral

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Shoulder Motion

• Initial contact with humerus in extension,
  abduction internal rotation
• Loading mechanics create potential for
  impingement

Newsam et al., 1999
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Shoulder Joint Reaction Forces

• Predominantly superior and posterior during push
  phase
• Superior force increases 3-fold during FAST and
  GRADED propulsion

superior
posterior
0 20 40 60 80 100
PUSH
Kulig et al., 1998
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PUSH Phase Muscles
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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
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RECOVERY Phase Muscles
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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
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Demands of Depression Transfers Raises

• High Superior shoulder forces 50 of body
  weight
• High muscle intensity with prolonged duration
• Low repetition

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

• Weakness or fatigue threatens
• G-H joint integrity

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Depression Transfer LOW Paraplegia
N 12
MMT
Perry et al., 1996
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Risk Factors for Shoulder Pain in SCI
Modifiable
Non-Modifiable
Age
Posture
Duration of SCI
ROM
SHOULDER PAIN
Anatomy
Body Mass
UE Trauma
Muscle strength
Functional Demands
Functional Demands
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STOMPS Protocol Design
Recruitment
Screening Pre-assessment
Randomized
Exercise/Optimization
Education
Post assessment
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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

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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

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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

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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

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Exercise Movement Optimization Program 12wks

• Stretching
• Shoulder / Rotator Cuff Strengthening
• Training / Instruction in Movement Performance
• WC Propulsion
• Transfers Raises

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Standardized Stretching Program

• Anterior Thoracic
• Posterior Capsule
• Upper Trapezius

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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

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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)

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Hypertrophy Exercise 8RM

• Diagonal pull-downs

• Pectoralis major
• Propulsion power
• Active in transfers
• Non-weight bearing

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Hypertrophy Exercise 8RM

• External rotation

• Infraspinatus
• PUSH phase of WC propulsion
• Active in transfers

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Endurance Exercise 15RM

• Scaption

• Supraspinatus
• Active in both PUSH RECOVERY phase of WC
  propulsion

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Endurance Exercise 15RM

• Scapular Retraction

• Rhomboids
• RECOVERY phase of WC propulsion at 62 PC duration

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Movement Optimization

• Transfers
• Modify height of transfer surface
• Hand arm position
• WC Propulsion
• Propulsion technique
• Energy conservation

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Thank You
Pathokinesiology Laboratory