Title: Aging with Spinal Cord Injury: Changing Mobility Needs
1Development 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
2 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
3Research Program Development from a Clinical
Perspective
- Identification of the problem
- Identification of potential cause
- Development of treatment program
4Living 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
5Shoulder Pain with SCI
lt 5 5 - 9 10 - 14 15 - 19 gt 20
Years since onset
Sie et al., 1992
6Shoulder 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
7The Weight-Bearing Shoulder
- Shoulder designed for locating the hand in the
environment
8Rotator Cuff Tendinopathy
- Rat shoulder model
- Trauma combined with Overuse
- Greater tendon thickness
- Reduced load to failure
Soslowsky et al., 2002
9Functional Demands Associated with Shoulder Pain
in SCI
- Manual WC Propulsion
- Pressure Relief Raise
- Depression Transfers
- Overhead Activities
10Demands of Manual WC Propulsion
- Highly repetitive
- Weight bearing
- Bilateral
11Shoulder Motion
- Initial contact with humerus in extension,
abduction internal rotation - Loading mechanics create potential for
impingement
Newsam et al., 1999
12Shoulder Joint Reaction Forces
- Predominantly superior and posterior during push
phase - Superior force increases gt 3-fold during FAST and
GRADED propulsion
superior
posterior
0 20 40 60 80 100
PUSH
Kulig et al., 1998
13PUSH Phase Muscles
14PUSH 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
15RECOVERY Phase Muscles
16RECOVERY Phase Muscles
- Decelerate arm reposition hand
- Humeral Elevators
- Middle Posterior Deltoid
- Rotator Cuff
- Subscapularis Supraspinatus
- Scapular Muscles
- Middle Trapezius (Rhomboid)
Mulroy et al., 1996
17Demands of Depression Transfers Raises
- High Superior shoulder forces 50 of body
weight - High muscle intensity with prolonged duration
- Low repetition
18Depression Transfers Raises
Latissimus Dorsi Pectoralis Major elevate trunk
protect G-H joint
Reyes et al., 1995 Perry et al., 1996
19Depression Transfers Raises
- Weakness or fatigue threatens
- G-H joint integrity
20Depression Transfer LOW Paraplegia
N 12
MMT
Perry et al., 1996
21Risk 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
22STOMPS Protocol Design
Recruitment
Screening Pre-assessment
Randomized
Exercise/Optimization
Education
Post assessment
23Enrollment Criteria
- INCLUSION
- Paraplegia from SCI
- Shoulder pain
- Propel manual WC gt 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
24Recruitment 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
25Education 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
26Standardized 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
27Exercise Movement Optimization Program 12wks
- Stretching
- Shoulder / Rotator Cuff Strengthening
- Training / Instruction in Movement Performance
- WC Propulsion
- Transfers Raises
28Standardized Stretching Program
- Anterior Thoracic
- Posterior Capsule
- Upper Trapezius
29Standardized 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
30Standardized 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)
31Hypertrophy Exercise 8RM
- Pectoralis major
- Propulsion power
- Active in transfers
- Non-weight bearing
32Hypertrophy Exercise 8RM
- Infraspinatus
- PUSH phase of WC propulsion
- Active in transfers
33Endurance Exercise 15RM
- Supraspinatus
- Active in both PUSH RECOVERY phase of WC
propulsion
34Endurance Exercise 15RM
- Rhomboids
- RECOVERY phase of WC propulsion at 62 PC duration
35Movement Optimization
- Transfers
- Modify height of transfer surface
- Hand arm position
- WC Propulsion
- Propulsion technique
- Energy conservation
36Thank You
Pathokinesiology Laboratory