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Hello! Julie Grant, MOT, OTR/L Jill McVey, DPT, LAT, ATC
REvolutionary shoulder care!
Participants will be able to name thought patterns that can influence pain and functional outcomes.
Participants will be able to identify specific mechanical aspects of wheelchair use to reduce stress/strain on the shoulder girdle.
Participants will be able to describe key differences between controlled mobility and general flexibility.
Julie and Jill have no conflicts of interest to disclose. The search for truth is difficult and messy. The information in this presentation is intended to be for general education, and not a substitute for individualized, skilled care.
Shoulder function is a REFlECTION oF movement system
wellness
● The integration of body systems that generate and maintain movement (biomechanical, cardiovascular, neuromuscular, visceral) 1
● Influenced by social, environmental, and personal factors 2
● Strengthened through variable and challenging experiences ● A lifelong commitment
pain is best conceptualized as the result of a complex interaction of biological, psychological, social, and cultural factors that shape
perceptions and response to musculoskeletal pathology 3
Are symptoms influenced by... The diaphragm? Emotions and beliefs? Social life? Past experiences?
YES!
Wheelchair Seating & Mobility
Sleep & Recovery
Diet
Exercise & Movement
“Do not let what you cannot do interfere with what you can do.” --John Wooden
Thought patterns
Commitment to Wellness
I must not fear. Fear is the mind-
killer...
If I do that, I’ll damage by body.
This pain is terrible and it’s never going to
get any better. I’m afraid of
getting hurt, so I won’t ever do that activity
again.
● Looked at psychosocial factors that influence outcomes and activity levels
● Found an association of maladaptive fear avoidance factors to musculoskeletal pain intensity, as well as activity limitations, in active wheelchair users
Pain Catastrophizing
Pain
Reduced activity
Reference #4
Perception
Expectation has a strong influence on how pain is perceived - whether low or high pain.
Anticipation
Expectation of a negative outcome may induce the worsening of symptoms
Suggestion
Negative verbal suggestions can trigger anticipatory anxiety, release of hormone (CCK), and facilitate pain transmission
What is a nocebo?
Reference #5
● Self-efficacy is the belief we have in our own capabilities and ability to produce an outcome.
● These beliefs influence behavior including: effort given, stress experienced, and perseverance towards challenges.
● Task accomplishment may be influenced by what an individual thinks they can do, in addition to their actual ability to accomplish the physical task.
● “Interventions to promote self-efficacy to support maintenance and improvements in physical function in individuals with SCI/D are warranted.”
● Employ biopsychosocial paradigm
● Seek multidisciplinary care including therapy/counseling to decrease negative thought patterns and increase optimal
● Teach people about cognitive factors associated with pain, and pain related behaviors
● Activities in physical rehab should challenge thought patterns to ensure true change
Wheelchair related
modifiable factors
Seating and positioning
Pressure relief
Propulsion technique
Transfer technique
“The willingness to experiment with change may be the most essential ingredient to success at anything.” --Pat Summitt
Strategies to increase postural control: ● Front seat to floor > rear seat to floor ● Perpendicular backrest ● Short backrest to allow normal spinal curves
● Elisa Smith and Holly Wakefield, physical therapists from Mobility Coaching & Outfitting, recommend placing ultra-lightweight wheelchair axles 2” in front of the shoulder, or as far forward as possible without creating posterior instability (aka tippiness).
● Further shoulder preservation advice, “Look at all ways to customize the chair.”
● Focus on smooth long strokes ● Coast between pushes, reducing stroke frequency ● Use an oval shaped push pattern, with hands dropping below the push rim
during “recovery phase” ● Will need to adjust when pushing uphill
Wheelchair pushing technique videos from The SCI Empowerment Project http://sci.washington.edu/empowerment/videos.asp#push
● Better transfer technique was correlated with less supraspinatus tendinopathy, and less shoulder pain during transfers. 9
● Transfer Assessment Instrument: http://www.upmc-sci.pitt.edu/node/933
● Transfer technique videos from The SCI Empowerment Project: http://sci.washington.edu/empowerment/videos.asp#transfer
● Opt to weight shift by leaning forward, or with lateral leans to each side.
● Highest joint forces in the shoulder associated with pressure relief, ramp propulsion, and start of propulsion.10
Movement Fitness
sport
Movement Fitness
sport
Reference #11
Wheelchair Seating & Mobility
Sleep & Recovery
Diet
Exercise & Movement
“Do not let what you cannot do interfere with what you can do.” --John Wooden
Thought patterns
Commitment to Wellness
● No current standards for wheelchair users; recommendations in research literature for paraplegia not applicable to tetraplegia. Difficulty balancing work vs recovery.
● Need to consider all components to mechanics: ○ Joint mobility / range of motion ○ Muscle length / stiffness ○ Strength / muscle balance ○ Movement patterns
● Pain-free overhead shoulder motion requires joint mobility (of arm, shoulder blade, collarbone, trunk), as well as muscle flexibility.1
● Maintaining full range of motion keeps joint surfaces healthy, reduces joint capsule stiffness, and reduces pain due to mismatched force coupling. 12, 1, 13
● Distinguish between joint mobility vs isolated muscle stretching. Stretch/move into nonpainful restriction, not ease.1
● Mobility in and of itself is not self-care. Controlled mobility is.
In mechanical systems, movement occurs along the
path of least resistance 1 range of motion / mobility
work needs to “lock down” the least resistant path in order to move the most resistant.
● Joint mobility: 3-5 rounds of 30 seconds per joint -- can reduce pain with tiny oscillations or increase joint motion with larger. 13
● Stretching: 3 rounds of 30 seconds per muscle, with adjacent areas stabilized. Need at least 6 days/week x 8-11 weeks to see length changes. Stiff muscles need less coaxing.
● For best results, perform joint mobility prior to movement (loading the newly available movement to keep it).
● Consider timing of muscle stretching -- will reduce force production of the muscle for up to 40 minutes. What are your goals? 14
Get pumped up about pumping
up
Muscularly balanced shoulders are less likely to be injured 15
Strength programs reduce shoulder pain across
multiple studies 10
Resistance training improves mood, metabolism, movement patterns 16
Opportunities to make friends, strengthen personal network
Can start 1x/week at home Makes moving through life easier
● Multiple effective programs in the research literature; all recommend strengthening posterior shoulder and stretching anterior shoulder. 12, 17, 10, 18
● Multiple studies recommend resisted external rotation to reduce pain and strengthen rotator cuff, as well as adduction
● Julie and Jill recommend working towards pain free, loaded overhead mobility to balance significant downward pull of lats. Trapezius, serratus anterior, rotator cuff. Consider upper back extension exercises.
● Latissimus dorsi also challenges the abdominals and trapezius for trunk control. Include abdominal / core exercises as much as possible (they attach as high as rib 5!).
● Motor variability is an inherent and beneficial characteristic of healthy neuromotor systems. 19
● Repetitive movements are most likely to be associated with injury.1, 20
● Elite athletes never make the exact same movement twice. 21
● Ambulatory individuals with knee, shoulder, and low back pain demonstrate less variability than pain-free peers.
● Pilot study suggests reduced variability of manual wheelchair propulsion technique when shoulder pain is present (chicken and egg?)
● Fear avoidance behavior reduces motor variability. 4, 22
● Landmark 2011 study; first to investigate the effect of a home based program on shoulder pain in people with SCI.
● Included stretching, warm up, strength / endurance exercises and movement education.
● Participants significantly reduced shoulder pain intensity but did not increase physical activity or community participation.
● Multiple variables with only one control group. ● Generalizable only to individuals with paraplegia.
Research suggests a relationship between anterior shoulder stretching and reducing pain. Multiple studies validate incorporation of shoulder external rotation exercises. Shoulders are used frequently in protraction / medial rotation to transfer or propel. 17
Keep chest stretch, discontinue posterior shoulder and upper trap stretches. Add lat dorsi stretch. Continue using, consider adding variety to keep interest. Incorporate serratus anterior and subscapularis strengthening into program to improve soft tissue balance.
*But really, any pain-free movement is good movement
Fitness AND shoulder healtH Fitness AND shoulder health
● Dehydration reduces strength by 2%, power by 3%, and high-intensity endurance by 10%. 23
● Eat an optimal balance of protein, carbs, fat, vitamins/minerals to promote tissue repair / recovery.
● Body weight significantly contributes to shoulder pain. Recommendation to retool BMI cutoff for obesity from 30 kg/m2 to 25 kg/m2. Healthy for shoulders and heart. 24, 25, 26
● Recommendation to reduce 1 MET from 3.5 → 2.7 ml O2/kg/min27
● Potentially need an additional 43.3 min/day, 7 days/week to achieve cardiovascular benefit of MWC propulsion, analogous to walking for heart health. 27
● 2018 adjusted exercise guidelines for SCI 28: ○ Moderate to vigorous intensity x 20 min, 2x/week (down
from 30) ○ Three sets of strength exercises for each major functioning
muscle group, moderate-vigorous intensity, 2x/week
● Sport participation does not increase risk of shoulder pain. No difference in shoulder pain rates between active and sedentary individuals. 29, 30
● Some studies report a protective effect for both paraplegia and tetraplegia. 29, 17
● Positively impacts mental health (markedly), social relationships, employment status, community reintegration 31
Self - care
● 2018 case report: paratriathlete with shoulder pain ● Female, reporting increasing shoulder pain intensity and
irritability with sport participation. ● Diagnosed with SLAP lesion and rotator cuff tear. ● Treated with cortisone injection, physical rehabilitation focusing
on scapular stabilization and shoulder external rotation, temporary reduction in training volumes.
● 90% improved in two weeks.
● The athlete received rapid intervention, utilizing multiple members of their health care team
● Activity was reduced but not eliminated, so strength didn’t deteriorate, but athlete was still able to reduce stress on shoulder
● Completed an evidence-based and specific progressive strength / stability program, prescribed with a “forest from the trees” approach
● Athlete’s body was already in peak condition, making repair easier with optimized body systems
“Oh S@!*” ● Definite tissue injury, can isolate to
a specific moment. ● Seek immediate care to rule out
significant damage, advice for self care.
● Protect, active rest. Ease back in slowly, limiting weight bearing.
● Six week regression to the mean. 32
“Huh, that’s funny…” ● Pain just starts without injury. ● Assess for recent change in
activity or movement. Consider / self treat known flexibility or strength issues.
● Seek help if no change in 2 weeks or less.
Hangouts with friends!
Sports!
Fitness!
Hangouts with friends!
I N J u
R y
Hangouts with friends!
Hangouts with friends!
● Biopsychosocial: An approach that looks the interaction and interconnection between biological, psychological, and social factors.
● Pain is Really Strange by Steve Haines ● The Brain That Changes Itself by Dr. Norman Doidge, M.D. ● Mind Gym: An Athlete’s Guide to Inner Excellence by Gary Mack with David Casstevens ● Mindsight: The New Science of Personal Transformation by Daniel J. Siegel ● The Mindful Therapist: A Clinician's Guide to Mindsight and Neural Integration by Daniel J. Siegel ● Reach for the Summit: The Definite Dozen System for Succeeding at Whatever You Do by Pat
Summitt with Sally Jenkins ● Wooden: A Lifetime of Observations Both On and Off the Court by John Wooden and Steve Jamison
45
1. Sahrmann SA. (2002) Diagnosis and Treatment of Movement Syndrome Impairments. St. Louis, Missouri: Mosby. 2. American Physical Therapy Association, 2019.
3. Eriks-Hoogland, I., de Groot, S., Snoek, G., Stucki, G., Post, M., & van der Woude, L. (2016). Association of shoulder problems in persons with spinal cord injury at discharge from inpatient rehabilitation with activities and participation 5 years later. Archives of Physical Medicine and Rehabilitation, 97(1), 84-91. doi:http://dx.doi.org/10.1016/j.apmr.2015.08.432
4. Finley, M. A., & Euiler, E. (2019). Association of musculoskeletal pain, fear-avoidance factors, and quality of life in active manual wheelchair users with SCI: A pilot study. The Journal of Spinal Cord Medicine, , 1-8. doi:http://dx.doi.org/10.1080/10790268.2019.1565717
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7. Hastings, J., & Goldstein, B. (2004). Paraplegia and the shoulder. Physical Medicine and Rehabilitation Clinics of North America, 15(3), 699. doi:10.1016/j.pmr.2003.12.005
8. Boninger, M. L., Koontz, A. M., Sisto, S. A., Dyson-Hudson, T. A., & et al. (2005). Pushrim biomechanics and injury prevention in spinal cord injury: Recommendations based on CULP-SCI investigations. Journal of Rehabilitation Research and Development, 42(3), 9-19
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