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causes, cures & remedies
It's no surprise that many people with
spinal cord injuries have aches and pains. Often, that aching and
paining targets the joints. And, with arms needing to do their own job,
as well as having to serve as "surrogate legs" - transferring,
using wheelchairs, maybe even pedaling handcycles - no one will be
shocked to hear that the most achy joint of all is the shoulder.
Shoulder Pain Is Common
Numerous studies have shown how common shoulder pain is. In one
international effort involving more than 600 British, Canadian and
American people with SCI - all of whom had been injured 20 or more years
- about one-third of those who participated complained of shoulder pain.
Things were pretty similar in a second long-term study as well. Of 751
Americans with spinal cord injuries - all injured at least 10 years -
280, or 37%, had shoulder pain or stiffness. Other studies have reported
shoulder pain to affect from 30% to more than 50% of spinal cord injury
survivors. Percentages like these put spinal cord injury survivors with
achy shoulders right up there with the best of them - competitive
swimmers - but with none of the glory!
So, what kinds of things predict shoulder pain? Surprisingly, in the
international study, there was no data to show that how active, busy, or
independent you are is the culprit. Various ways of measuring how active
people were - time working, hours out of bed, days out of the house per
week, or the amount of attendant care they used - did not predict
shoulder pain several years later. In fact, another study actually found
complaints of shoulder pain to be more common among those who
What about age and length of time
injured? Do these predict shoulder pain? Although some researchers are
finding more shoulder pain in people who are older and have been injured
longer, other researchers have not found this to be the case. It seems
that the jury is still out on this one.
So what really does predict
shoulder pain? In several studies, manual wheelchair use was found to be
a predictor. In the three-nation study, those who used manual
wheelchairs for mobility (rather than braces or crutches) were more
likely to have shoulder pain in three years. This was verified by other
studies. One even found that, on x-ray, the shoulders of wheelchair
pushers had more joint deterioration than the shoulders of full-time
crutch walkers. Having paraplegia also may be predictive. Perhaps more
important, however, was whether the individual had had shoulder pain previously.
Half of those in the international study who had shoulder pain when they
first joined the study still had it three years later. In a US study of
more recently injured people, about a third of those with shoulder pain
at one follow-up point, still had it five years later.
If you do have shoulder pain, what causes or aggravates it? The answers
to this question are surprisingly consistent across numerous
researchers' studies: pushing a manual wheelchair, especially out of
doors on rough and uneven terrain; transferring; weight shifting;
driving a vehicle; and upper body dressing. What about sports? In one
study, 77% of all people with spinal cord injuries who were involved in
sports were complaining of shoulder pain!
Regardless of what does or
doesn't predict shoulder pain, the things that aggravate it seem clear.
And, they make sense when you think about the principles and mechanics
of shoulder injury, even in the nondisabled population.
Five Facts to Keep in Mind
Here are five things that we know about shoulders in general:
- We know that repeated or
sustained raising of your arm up over your head or out to the side -
like swimmers do - can increase the forces sustained inside your
shoulders to an amount that approaches your body weight. This
translates to pain, stiffness and fatigue. Are you constantly
reaching up to high shelves? When you push your chair, are your
elbows angled out? Even this can increase the forces inside your
shoulders. No, you can't stop reaching and you can't stop pushing
your chair. But you can make modifications: Rearrange your work area
so the number of overhead reaches is lessened. Think about ways that
you can change how you sit in your wheelchair, so your arms can be
tucked in a bit closer to your body as you push: what about closer
or lower armrests? a cushion that lets you sit higher up from the
wheel? a narrower chair? (But, remember: as you try these solutions,
be aware of what else you might be affecting - especially skin and
posture.) Should you try a power chair? Maybe. How drastic a
solution a power wheelchair is depends on how severe the pain is.
- We know that chronic
compression - or forcing the shoulder into its socket - also exerts
a lot of force inside the shoulder joint. This is especially true
when your body is moving while your hand stays put. Think of a
gymnast working out on the pommel horse or doing a floor routine.
Now think about doing a tub or a sofa transfer, or getting into a
high four-wheel-drive vehicle: there's not a whole lot of
difference. You can't stop doing these things, but you can lessen
the forces they create. Raise that sofa, or get a tub bench so the
height of what you're going to is closer to the height of your
wheelchair. This lets you reduce that amount of actual lifting
you need to do to transfer. Of course, using a transfer board can
further reduce the compression forces your shoulders are subjected
to. At the very least, do things to minimize the absolute number
of transfers you have to do.
- We also know that muscle
imbalance - stronger muscles on one side of the joint than the other
- contribute to uneven shoulder wear and tear. Wheeling typically
strengthens only the muscles on the front side of your shoulder.
There is, in fact, very little we do functionally to strengthen the
muscles on the backside of the shoulder joint. Some therapists
recommend rolling your wheelchair backwards as part of a workout.
Need other ideas? - Think of exercises that require you to pull
against resistance - pulling down from over your head, or pulling
back from in front of you. Weight machines that provide resistance
while you do these movements can be found at almost any fitness
center. If you need other ideas or more help, check with a trainer,
PT, or OT.
- We know that shoulders are
affected by posture. We just talked about your position while
wheeling, but your posture when you're just sitting - especially at
work - is also very important. How you sit, lean, even lie, alters
the way forces are distributed throughout your shoulder joint. Take
a look at a side view of yourself in a mirror. Your ear, your
shoulder, your hip joint and the axle of your chair should pretty
much make a straight line perpendicular to the ground. If they
don't, it might be time to check with a PT or OT who understands
posture and the equipment and modifications that improve it.
- Finally, we also know that everyone's
musculoskeletal system changes and deteriorates with age. Small,
gradual strength losses appear with each decade as we get older.
Cartilage deteriorates, and arthritic changes in joints are the norm
rather than the exception. What can you do? Know that no one is
immune, no one is immortal. Make choices to at least minimize and
delay such aging-related changes as much as possible. If you're
already having pain, get together with someone in-the-know who can
help you problem solve. Remember: one of the biggest predictors of
having shoulder pain in the future is having had it earlier. It
isn't going to just go away on its own. Figure out what causes or
aggravates your pain, and change it!
This is part of a library of
educational brochures developed by Craig Hospital with a federal grant
titled, "Marketing Health Promotion, Wellness, and Risk Information
for Spinal Cord Injury Survivors in the Community." The opinions
expressed here are not necessarily those of the funding agency, the
National Institute on Disability and Rehabilitation Research of the US
Department of Education.
For a hard copy of this brochure,
click on your selection above and hit the "print" button on
your browser. If you'd like to ask for one directly from Craig Hospital,
you can contact them by telephone at 303-789-8202, or you can e-mail
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