Reducing Shoulder Pain in Manual Wheelchair Users

Josh Albarado, Caitlin O’Toole & Ashton Stair

Primary Article: Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury

Statistics● In North America, the number of wheelchair users has grown faster than the

growth of the total population.

● 1993: 1.5 million wheelchair users in America

● 2003: 2 million wheelchair users in America

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Prevalence of shoulder pain in people with paraplegia

30-50%

Risk factors for shoulder pain ● Repetitive use or sustained elevated

shoulder postures

● Exposure to routine overhead work

● Repetitive and nearly exclusive use of

the upper limbs during self-care,

weight-relief raises, transfers, and

wheelchair mobility

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Subacromial impingement● Pain has been linked to functional compromise of the subacromial space and structures

within the space:

○ Rotator cuff

○ Long head of the biceps brachii

○ Bursae

● Contributing factors:

○ Changes in acromial shape and slope

○ Poor rotator cuff or scapular muscle function

○ Posterior capsule and/or pectoralis minor tightness

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Purpose

To determine the effects of a controlled 8-week, scapula-focused exercise intervention

on shoulder pain and functional disability in people with SCI and symptoms of

shoulder impingement.

Hypothesis

Subjects in the intervention group would show significant improvements over time,

whereas subjects in the asymptomatic control group would retain stable functional

status over time, as measured with the Wheelchair User’s Shoulder Pain Index

(WUSPI), the Shoulder Rating Questionnaire (SRQ), and patient satisfaction scores.

Methods ● Subjects

● Outcome Measures

● Experimental Procedure for Intervention Group

● Exercise Intervention

● Data Reduction

● Data Analysis

Subjects ● Study Design: clinical trial with an

asymptomatic control group.

● Population: manual w/c users with SCI

(paraplegia and incomplete tetraplegia) and

spina bifida (1)

● People with and without current self-reported

shoulder pain were recruited through local

clinics and SCI support groups.

● Inclusion criteria: at least 1 year after SCI,

current hx of unilateral or bilateral shoulder

pain lasting 3+ months and localized to the

proximal anterolateral shoulder region

Objective Measures

● Wheelchair User’s Shoulder Pain Index (WUSPI)

● Shoulder Rating Questionnaire (SRQ)

● Patient Satisfaction Scores

Experimental Procedure for Intervention Group ● Pretest

● Home exercise program

○ Stretching & Strengthening exercises

○ 4 weeks

○ 8 weeks

● Posttest

*Adherence to exercise program was established through self-report written adherence

logs and weekly verbal communication

Exercise Intervention ● Muscles tested:

○ Serratus Anterior

○ Pectoralis Major

○ Upper, Middle, and Lower Trapezius

*Bipolar surface electrodes were placed over these muscles to provide visual and

auditory feedback to the subjects as they were performing the exercises, thereby

allowing the subjects to modify the exercise technique until it was properly done.

*Anatomical education given for each exercise

Stretching Exercises

Targeted:

● Upper Trapezius Muscle

● Pectoralis Major and Minor Muscles

● Long Head of the Biceps Brachii Muscle

Strengthening Exercises

Targeted:

● Serratus Anterior Muscle

● Middle and Lower Trapezius Muscles

● Shoulder External Rotator Muscles

Data Reduction & Analysis

● A lower score on the WUSPI indicates decreased pain and increased function.

● A higher score on the SRQ indicates greater shoulder function and fewer shoulder

impingement symptoms.

● “How would you rate your overall degree of satisfaction with your shoulder?”

● Normality was assessed for each of the 3 dependent variables (WUSPI, SRQ, and

satisfaction scores).

Results

● 95% of all subjects returned at 8 weeks

● All subjects in asymptomatic control group returned for 8-week visits

● Two subjects in the intervention group were lost to follow-up

Intervention Group

● 19 subjects returned for 8-week follow-up: 14 adherent, 3 moderately adherent, 2

non-adherent

● Significant improvements in WUSPI, SRQ, and patient satisfaction scores from

pretest to posttest

Asymptomatic Control Group

● No significant improvements in WUSPI, SRQ, and patient satisfaction scores

Discussion

● Subjects used EMG biofeedback if necessary

● Exercise performance was reviewed, corrected, and augmented at the 4-week follow-up and

decided if they could increase resistance

● A selective 8-week scapula focused home exercise program is effective in reducing pain and

improving function and satisfaction in this population with full scapular muscle innervation

● Maximum recovery not achieved; continued investigations needed for greater recovery

Modifications for shoulder pain - research by Dalyan, Cardenas, and Gerard

● 130 patients with tetraplegia or paraplegia answered a questionnaire

○ 76 with UE pain

■ 48 sought medical treatment of different forms

● Found that although the approaches like wheelchair modification, home

modification, and education in joint protection techniques were prescribed less

than the traditional modalities, they reduced UE pain in most of the patients

Occupational therapy’s role in reducing shoulder pain in MWC

● Occupational Therapists typically focus on UE functionality, which MWC users

rely heavily on for mobility, ADLs, and IADLs

● OTs could administer stretches and exercises to reduce shoulder pain, BUT a

personally meaningful occupation-based intervention would be more beneficial

for client’s overall well-being

● Training and using a service dog falls under the scope of practice of occupational

therapy

Effect of service dogs on manual wheelchair users with spinal cord injury: A pilot study

● Objective was to document the effect of a service dog on MWC mobility and user

shoulder pain, social participation, and quality of life.

● 11 MWC users with spinal cord injury were assessed before and after training with

a service dog for 7 months

Objective & Methods

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Results & Relevance● After 7 months, a significant decrease in shoulder pain was found in all

participants

● Service dogs decreased the intensity of effort needed to propel MWC

● Social participation and ability to return to “normal” life improved after 7 months

of using service dogs

Service Dog Simulation

Featuring Dr. Susan Wilbanks, DPT and Izzy

*Therapy Dog vs Service Dog

Occupation-based intervention strategy● Service dogs help to achieve optimal level of functional independence in ADLs,

while also providing an individual with the occupation of caring for a dog

● Tasks which service dogs are trained in:

○ Self-care

○ ADLs such as dressing

○ Transferring to and from the MWC

○ Retrieving the telephone

○ Opening doors

○ Picking up objects like keys

○ Facilitating social relationships

○ Pulling/pushing the MWC

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Benefits of service dogs1. Psychological well-being

2. Self-esteem

3. Internal locus of control

4. Community integration

5. School attendance

6. Part-time work status

7. Marital status

8. Living arrangements

9. Number of biweekly paid and unpaid assistance hours

10. Cost-effective component of independent living

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Resources Wisconsin Academy for Graduate Service Dogs (WAGS)

http://www.wags.net

OccuPaws Guide Dog Association

http://occupaws.org

The Teacher’s Pet Dog Training LLC

http://www.theteacherspetdog-training.com/Therapy_Service_Training.html

Questions?“Been reading up on the thesaurus lately because a mind is a terrible thing to garbage.”

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ReferencesDalyan, M., Cardenas, D. D., & Gerard, B. (1999). Upper extremity pain after spinal cord injury. Spinal Cord, 37(3), 191-195.

Hubert, G., Tousignant, M., Routhier, F., Corriveau, H., & Champagne, N. (2013). Effect of service dogs on manual wheelchair users with spinal cord injury: A pilot study. The Journal of Rehabilitation Research and Development JRRD, 50(3), 341.

Isaacson, M. (2013). The training and use of service dogs in occupational therapy education. The Open Journal of Occupational Therapy, 1(2), 1-13. Doi: 10.15453/2168-6408.1023

Nawoczenski, D. A., Ritter-Soronen, J. M., Wilson, C. M., Howe, B. A., & Ludewig, P. M. (2006). Clinical Trial of Exercise for Shoulder Pain in Chronic Spinal Injury. Physical Therapy, 86(12), 1604-1618.