Shoulder Evaluation for Wheelchair Users: An Evidence Based Approach for Clinicians

Martin J. Kilbane, PT, OCS 31st International Seating Symposium February 27, 2015 Nashville, TN

Learning Objectives Upon completion of this lecture participants will be able to: 1. List two pathologies of the glenohumeral joint and scapulothoracic joint common to individuals with spinal cord injury 2. List three available research and current evidenced based practice sources on examination techniques for the shoulder complex. 3. List three basic shoulder examination techniques to appropriately identify structural pathology and assist in determining appropriate wheelchair selection.

Overall Goal of Presentation Are we utilizing the best available evidence for examination of the shoulder complex when prescribing wheelchairs?

Evidence doesn’t tell us everything, but it certainly tells us a lot!

Why the big fuss?

Incidence in SCI • According to the Consortium for Spinal Cord Injuries Clinical Practice Guidelines 2005 (Surveys and Cross Sectional Studies) it is estimated to be up to 60%.

• Shoulder pain is a problem in up to 86% of persons with spinal cord injury. • Eriks-Hoogland IE, Hoekstra T, de Groot S, Stucki G, Post MW, van der Woude LH. Trajectories of musculoskeletal shoulder pain after spinal cord injury: Identification and predictors. J Spinal Cord Med. 2014 May;37(3):288-98.

•

General Population: – 30% of people experiencing shoulder pain at some stage of their lives up to 50% of the population experiencing at least one episode of shoulder pain annually. • Lewis JS. Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new method of assessment? Br J Sports Med. 2009 Apr;43(4):259-64.

Why do we need to revolutionize care? • Only 2% of this population undergoes shoulder surgery treatment for rotator cuff tear and shoulder disability (out of 60% who reported pain). • Pellegrini A, Pegreffi F, Paladini P, Verdano MA, Ceccarelli F, Porcellini G. Prevalence of shoulder discomfort in paraplegic subjects. Acta Biomed. 2012 Dec;83(3):177-82.

• Reduction in shoulder pain were related to significant increases and social participation and improvements in quality of life in people with long term paraplegia.

• Kemp BJ, Bateham AL, Mulroy SJ, Thompson L, Adkins RH, Kahan JS. Effects of reduction in shoulder pain on quality of life and community activities among people living long-term with SCI paraplegia: a randomized control trial. J Spinal Cord Med. 2011;34(3):278-84.

Risk Factors in SCI • • • • • • • •

Duration of injury Older age Higher BMI Use of manual wheelchair Poor seated Posture Decreased Flexibility Muscle imbalances of the rotator cuff and scapula stabilizers With a better understanding of the epidemiology, etiology, and basic patho-mechanics of shoulder pain in SCI, clinicians are in a better position to evaluate, treat, and prevent these disorders. Dyson-Hudson TA, Kirshblum SC. Shoulder pain in chronic spinal cord injury, Part I: Epidemiology, etiology, and pathomechanics. J Spinal Cord Med. 2004;27(1):4-17.

SCIRE Project summary www.scireproject.com

•

The shoulder is the most common joint above the level of injury where pain complaints are reported with persons with paralysis (tetraplegia or paraplegia) (Apple 2001).

• The shoulder is not well designed to handle the higher intra-articular pressures required for both weight bearing and mobility (Apple 2001). •

• • • •

Partial innervation and impaired balance of shoulder, scapular and thoracolumbar muscles place individuals with tetraplegia at a higher risk for developing shoulder pain especially during weight-bearing upper limb activities such as wheelchair propulsion, transfers, and pressure reliefs. Due to differences in trunk postural control, differences may also occur between individuals with high paraplegia (T2-T7) and low paraplegia (T8-T12). Individuals with C1-C4 motor levels of injury are also at risk for shoulder pain SCI severity also may be associated with shoulder pain (Dyson-Hudson & Kirshblum 2004). Lack of use of immobilization of the shoulder girdle muscles can limit their active joint movement and lead to muscle shortening and shoulder capsule tightness.

SCIRE Project summary www.scireproject.com

• • • • • •

•

The development of pain is associated with decreased shoulder ROM Weakness and paralysis in these muscles can lead to increased reliance on the trapezius, which can result in overuse and pain in this muscle. Shoulder pain can occur from nerve root injury or radicular pain with dysesthesias or phantom sensations People of certain age groups, those with higher cervical lesions and those with shorter lengths of bed rest may be at a greater risk Gender may be associated with shoulder pain in individuals with SCI (Pentland & Twomey 1991). Body mass index (BMI) also may play a role in shoulder injuries in manual wheelchair using individuals with SCI because it directly relates to the amount of physical strain experienced during ADLs in these individuals (Bonninger et al. 2001; Jensen et al. 1996). Shoulder pain is more common in individuals with tetraplegia and complete injuries and in women and duration of injury, older age, and higher BMI all may be risk factors for developing shoulder pain and/or abnormalities in persons with SCI (Dyson-Hudson & Kirshblum 2004).

Technicians

vs.

Clinicians

Clinicians vs.

Technicians

• As PT’s and OT’s:

– Doctoral and Master’s Level Education – Experts in: Biomechanics and Functional Movement – Best trained Clinicians in functional rehab intervention

• As ATP’s and SMS’s

– Experts in Seating and Wheelchair Rx

Anatomy of the Shoulder • Starting point for Clinicians – Must understand the Anatomy and Biomechanics to fully appreciate function.

• Shoulder is not just 1 joint! – Regional body complex made up of multiple joints. – Provides proximal stability for UE mobility.

Shoulder Complex Anatomy • Sternoclavicular joint • Acromioclavicular joint • Glenohumeral joint • Scapulo-thoracic joint

• Associated Musculature

Shoulder Complex Kinematics • Kinematics: Rotation occurs in all 3 principle axes • • • •

Abduction/Adduction Medial/Lateral Rotation (Internal/External Rotation) Flexion/Extension Circumduction

• Elevation: 180°

• Glenohumeral Joint: 120° • Scapulothoracic Joint: 60° • Extension: 45°-55° • IR with arm at side: 75°-85° • ER with arm at side: 60°-70° – 30° needed for GT to clear acromion

Muscular Stability of Glenohumeral Joint: Rotator Cuff • Supraspinatus, Infraspinatus, Teres Minor, and Subscapularis are innervated by nerve roots from: C5 and C6. • Impaired Rotator Cuff motor/strength will lead to Rotator Cuff dysfunction.

Key Scapula Stabilizers • Trapezius: CN XI, C3,4 – Middle and Lower

• Rhomboids: C4, 5 • Serratus Anterior: – Long Thoracic C5, 6, (7)

Breaking Down Biomechanics

Force Couples of the Shoulder Complex

Deltoid

↔

Rotator Cuff

Upper Trapezius ↔ Serratus Anterior & Lower Trapezius

• Clinically relevant structures not included for detailed discussion in this lecture due to time constraints:

– Sternoclavicular joint mechanics – A-C joint mechanics – Elbow joint mechanics – Wrist/hand mechanics – Trunk mechanics – Incomplete injuries with ability to ambulate

SCI Posture and Shoulder Dysfunction • Shoulder force couples are out of balance – – – – – – – – –

Hypertrophied Upper Trapezius Overactive Levator Scapula Elevated and Abducted Scapula Tight and over dominant Pectorals Weak Rhomboids Weak Lower Trapezius Weak Serratus Anterior Overactive & tight Shoulder Internal Rotators Weak Shoulder External Rotators

• Dysfunction: “Anterior dominant” shoulder

What happens to the body after Spinal Cord Injury?

When LE function is lost in SCI • Shoulder → Hip

• Elbow → Knee • Wrist/Hand → Ankle/Foot

Therapy Evaluation • History and Subjective Exam

– Ask the right questions! – Functional Outcome Measure: WUSPI

– Curtis KA, Roach KE, Applegate EB, Amar T, Benbow CS, Genecco TD, Gualano J. Development of the Wheelchair User's Shoulder Pain Index (WUSPI). Paraplegia. 1995 May;33(5):290-3.

• Systems Review:

need to rule out other causes

• Clinical Examination Findings – – – – – – –

Range of Motion (Functional ROM): Active and Passive Palpation: soft tissue and bony structures Manual Muscle Testing Posture Analysis Tissue Provocation Testing Differential Diagnosis/Special Tests Balance Testing/Trunk Control

Therapy Evaluation – Functional Activity Analysis: determine possible underlying causes and contributing factors – – – –

Observation of repeated movements Pressure Relief (Bed and Wheelchair) Bed Mobility skills Transfers (including advanced transfers) » Transfer Assessment Index

• Tsai CY, Hogaboom NS, Boninger ML, Koontz AM. The Relationship between Independent Transfer Skills and Upper Limb Kinetics in Wheelchair Users. Biomed Res Int. 2014;2014:984526.

– Seating Evaluation – Wheelchair Propulsion/Biomechanics • Smartwheel if available

– – – –

Wheelchair Skills ADL and IADL Assessment Work, school, and recreation activity analysis Understanding open vs. closed chain activities

Daily Activity Analysis

Weight-bearing Tasks • Potentially detrimental magnitude and direction of scapular and glenohumeral kinematics during weightbearing tasks may pose increased risk for shoulder pain or injury in persons with SCI/D. • Nawoczenski DA, Riek LM, Greco L, Staiti K, Ludewig PM. Effect of shoulder pain on shoulder kinematics during weight-bearing tasks in persons with spinal cord injury. Arch Phys Med Rehabil. 2012 Aug;93(8):1421-30.

• Both the weight-relief raise and transfer result in scapular and humeral positions and directions of motion that may negatively impact the available subacromial space. This may present increased risk for injury or progression of shoulder pain in persons who must routinely perform these tasks.

• Nawoczenski DA, Clobes SM, Gore SL, Neu JL, Olsen JE, Borstad JD, Ludewig PM. Three-dimensional shoulder kinematics during a pressure relief technique and wheelchair transfer. Arch Phys Med Rehabil. 2003 Sep;84(9):1293-300.

Weight-bearing Tasks • Forces beneath the trailing hand were larger than those in the leading, if there is weakness or pain in one arm, this arm should be selected as the leading. To avoid excessive load on the arms, technical aids and environmental factors should be very well adapted. • Forslund EB, Granström A, Levi R, Westgren N, Hirschfeld H. Transfer from table to wheelchair in men and women with spinal cord injury: coordination of body movement and arm forces. Spinal Cord. 2007 Jan;45(1):41-8.

• For participants who perform assisted or dependent transfers, use of an evidenced-based, structured education program during acute inpatient rehabilitation has the potential to significantly improve the quality of transfers.

• Rice LA, Smith I, Kelleher AR, Greenwald K, Hoelmer C, Boninger ML. Impact of the clinical practice guideline for preservation of upper limb function on transfer skills of persons with acute spinal cord injury. Arch Phys Med Rehabil. 2013 Jul;94(7):1230-46.

Weight-bearing Tasks •

Kankipati P, Boninger ML, Gagnon D, Cooper RA, Koontz AM. Upper limb joint kinetics of three sitting pivot wheelchair transfer techniques in individuals with spinal cord injury. J Spinal Cord Med. 2014 Aug 17.

•

Lin YS, Boninger M, Worobey L, Farrokhi S, Koontz A. Effects of repetitive shoulder activity on the subacromial space in manual wheelchair users. Biomed Res Int. 2014;2014:583951.

Wheelchair Propulsion vs. Gait

Ideal Propulsion Mechanics

Pictures with special permission from Kendra Betz (PN March 2007)

SmartWheel®

http://www.out-front.com/smartwheel_overview.php

Wheelchair Propulsion Assessment

What is the SmartWheel®? For each push, the SmartWheel Measures: • Push forces exerted on pushrim • Push frequency • Push length/angle • Push smoothness • Velocity Automated Reports Allow You To: • Review patient performance and outcomes • Compare outcomes with a national database • Compare with patient’s past performance

Propulsion Mechanics • Randomized control trial of strict use of the Paralyzed Veterans of America's Clinical Practice Guidelines for Preservation of Upper Limb Function affects wheelchair setup, selection, propulsion biomechanics, pain, satisfaction with life, and participation of individuals with new spinal cord injuries (SCIs). • The intervention group showed better skills on key wheelchair propulsion biomechanics variables related to upper-limb health. Use of a structured education program may be an effective method of educating new manual wheelchair users to prevent the development of upper-limb impairments in an inpatient setting. • Rice LA, Smith I, Kelleher AR, Greenwald K, Boninger ML. Impact of a wheelchair education protocol based on practice guidelines for preservation of upper-limb function: a randomized trial. Arch Phys Med Rehabil. 2014 Jan;95(1):10-19. • Paralyzed Veterans of America Consortium for Spinal Cord Medicine. Preservation of upper limb function following spinal cord injury: a clinical practice guideline for health-care professionals. J Spinal Cord Med. 2005;28(5):434-70.

Wheelchair Configuration • Research shows that vertical and horizontal wheel position are the most important adjustments to minimize impact on the UE during propulsion. • Horizontal: Move the rear wheel as far forward as possible w/o compromising the stability of the user. (CPG 2005) • Vertical: When the hand is on top of the rim, the angle between the arm and forearm should be between 100-120 degrees (CPG 2005) •

Theresa Berner Slide ISS 2013

Advanced Wheelchair Skills • • • • • • • • • • •

Wheelies Opening Doors Pushing and pulling open doors Negotiating Ramps Ascending and descending Negotiating Curbs Ascending and descending Floor Recovery Negotiating Stairs (when necessary) Should Include Advanced Transfers Advanced terrain (eg. grass, gravel, sand) • • •

Oyster ML, Smith IJ, Kirby RL, Cooper TA, Groah SL, Pedersen JP, Boninger ML. Wheelchair skill performance of manual wheelchair users with spinal cord injury. Top Spinal Cord Inj Rehabil. 2012 Spring;18(2):138-9. Hosseini SM, Oyster ML, Kirby RL, Harrington AL, Boninger ML. Manual wheelchair skills capacity predicts quality of life and community integration in persons with spinal cord injury. Arch Phys Med Rehabil. 2012 Dec;93(12):2237-43. Lindquist NJ, Loudon PE, Magis TF, Rispin JE, Kirby RL, Manns PJ. Reliability of the performance and safety scores of the wheelchair skills test version 4.1 or manual wheelchair users. Arch Phys Med Rehabil. 2010 Nov;91(11):1752-7.

“Weighing the options” • With daily activities require specialized ADL and IADL demands, propelling long distances, hills or uneven terrain, work duties, school demands, parenting duties….add on shoulder pain. • Which option is best:

– – – – – –

Manual wheelchair? Manual wheelchair with performance add-on? Manual with power assist wheels? Manual with power add-on? Basic power mobility? Complex power Wheelchair?

Classic Therapy Examination

Differential Diagnosis • Ruling out other causes – Visceral Referral

• • • • •

Clearing the Cervical Spine Balance Testing Trunk Control Posture Analysis Functional ROM – Active and Passive

• Palpation

– soft tissue and bony structures

• • • •

Manual Muscle Testing Tissue Provocation Testing Special Tests Joint and soft tissue mobility

Extrinsic Pain Referral • • • • • • • • •

Cervical Spine Neuropathic Cardiac Brachial Plexopathy Malignancy Infection Gall Bladder Spleen Diaphragm

– Post laparoscopy (phrenic nerve and shoulder share C3-5 innervation) • Walsh RM, Sadowski GE. Systemic disease mimicking musculoskeletal dysfunction: a case report involving referred shoulder pain. J Orthop Sports Phys Ther. 2001Dec;31(12):696701.

Basic Rules for Mechanical Pain • Symptoms present at time of Evaluation? • Can you produce the symptoms? • • • • •

Palpation Movement → Repeated Movement Posture → Sustained Posture Mechanical Resistance (MMT) Provocation Testing

• Can you make symptoms worse? • Can you make symptoms better? • No change in symptoms?

Ruling out Cervical Spine

Cervical Radiculopathy • The cervical spine can refer symptoms throughout the entire upper extremity and must be cleared from involvement for any pain in neck, scapula, shoulder, arm, hand.

Cervical Radiculopathy • Segmental Motor or Sensory signs associated with a nerve or nerve root disorder.

• Common Symptoms: – – – – – –

Pain in UE in dermatome pattern Decreased sensation in dermatome Weakness in myotome without spasticity Atrophy in muscle (late stages) May have hypoactive reflexes Parasthesias

• Magee DJ. Orthopedic Physical Assessment. 2013 • Slaven EJ, Mathers J. Differential diagnosis of shoulder and cervical pain: a case report. J Man Manip Ther. 2010 December; 18(4): 191–196. • Pateder DB, Berg JH, Thal R. Neck and shoulder pain: differentiating cervical spine pathology from shoulder pathology. J Surg Orthop Adv. 2009 Winter;18(4):170-4.

Mechanical Exam

4 Test Cluster for Cervical Radiculopathy 1. Positive Spurling’s Test -93% Specificity -Tong HC, Haig AJ, Yamakawa K. The Spurling test and cervical radiculopathy. Spine (Phila Pa 1976). 2002 Jan 15;27(2):156-9.

2. Positive Distraction Test 3. Positive Upper Limb Tension Test 4. < 60° Cervical Rotation to involved side. • 3/4 Positive (specificity of 94%) • 4/4 Positive (specificity of 99%)

• Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine (Phila Pa 1976). 2003 Jan 1;28(1):52-62.

4 Test Cluster 1.

2.

3.

4.

Palpation • Transdeltoid Palpation (Rent Test) – Full thickness rotator cuff tears.

– Wolf EM, Agrawal V. Transdeltoid palpation (the rent test) in the diagnosis of rotator cuff tears. J Shoulder Elbow Surg. 2001 Sep-Oct;10(5):470-3.

• A-C Joint –

• • • •

Walton J, Mahajan S, Paxinos A, Marshall J, Bryant C, Shnier R, Quinn R, Murrell GA. Diagnostic values of tests for acromioclavicular joint pain. J Bone Joint Surg Am. 2004 Apr;86-A(4):807-12.

Cervical Spine if cervical involvement Upper Trap with rotator cuff weakness Sup-Lat Shoulder Joint with Subacromial Impingement Anterior Joint Line with Osteoarthritis –

Manifold SG, McCann PD. Cervical radiculitis and shoulder disorders. Clin Orthop Relat Res. 1999 Nov;(368):105-13.

• Soft tissue: Myofascial Pain and Trigger Points

Myofascial Pain Syndrome • Common causes are poor posture (or sustained postures) and – – – –

overuse syndromes.

Abnormal muscle compensation: upper trap & levator scapula. Shoulder is now asked to be a weight-bearing structure. Upper extremity is primarily responsible for locomotion (manual w/c). Upper extremity must reach beyond normal ranges (sitting position).

Common Postural Deviations • Cervical Protrusion “Forward Head” • Protracted Shoulders and Scapulae – Classic “Rounded Shoulders”

• Increased Thoracic Kyphosis • Lumbar Kyphosis • Posterior Pelvic Tilt

Posture What is normal for individuals following Spinal Cord Injury?

Predisposition to Overuse • Functional reach in wheelchair users is dramatically reduced compared to ambulatory population.

• Required ROM for functional ADLs (Ambulatory): –

• Flex: 121° ±6.7°; Ext: 46° ±5.3°; ABd: 128° ±7.9° • cross body Add: 116° ±9.1°; ER with arm 90° ABd: 59° ±10° • IR with arm at side: 102° ±7.7°

Namdari S, Yagnik G, Ebaugh DD, Nagda S, Ramsey ML, Williams GR Jr, Mehta S. Defining functional shoulder range of motion for activities of daily living. J Shoulder Elbow Surg. 2012 Sep;21(9):1177-83.

Functional reach in wheelchair users Picture: Jaimie Borisoff, PhD (ASCIP 2014) IC22 Dynamic Wheeled Mobility: Next Chapter in the Ultralight Evolution Steve Mitchell, OTR/L, ATP and Jaimie Borisoff, PhD

Most common problems isolated to the shoulder region in SCI • • • • • •

Acromioclavicular Pathology Subacromial Impingement Syndrome Rotator Cuff Tear Long Head Biceps Tear Glenohumeral Arthritis Scapula Dyskinesia

A-C Joint Pathology

• •

•

Eriks-Hoogland I, Engisch R, Brinkhof MW, van Drongelen S. Acromioclavicular joint arthrosis in persons with spinal cord injury and able-bodied persons. Spinal Cord. 2013 Jan;51(1):59-63. Sousa CD, Camargo PR, Ribeiro IL, Reiff RB, Michener LA, Salvini TF. Motion of the shoulder complex in individuals with isolated acromioclavicularosteoarthritis and associated with rotator cuff dysfunction: part 1 -Three-dimensional shoulder kinematics. J Electromyogr Kinesiol. 2014 Aug;24(4):520-30. Sousa CD, Michener LA, Ribeiro IL, Reiff RB, Camargo PR, Salvini TF. Motion of the shoulder complex in individuals with isolated acromioclavicular osteoarthritis and associated with rotator cuff dysfunction: Part 2 - Muscleactivity. J Electromyogr Kinesiol. 2014 May 21.

A-C Joint Pathology • Pain reported precisely over A-C joint – Hypertonic Saline Injections into A-C –

Gerber C, Galantay RV, Hersche O. The pattern of pain produced by irritation of the acromioclavicular joint and the subacromial space. J Shoulder Elbow Surg. 1998 JulAug;7(4):352-5.

• Palpation –

Hegedus EJ, Goode A, Campbell S, Morin A, Tamaddoni M, Moorman CT 3rd, Cook C. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. Br J Sports Med. 2008 Feb;42(2):80-92;discussion 92.

• Compression –

Hegedus EJ, Goode A, Campbell S, Morin A, Tamaddoni M, Moorman CT 3rd, Cook C. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. Br J Sports Med. 2008 Feb;42(2):80-92;discussion 92.

A-C Joint Pathology Test Cluster • Cross Body Adduction Test • A-C Resisted Extension Test • O’Brien’s Test – 3/3 Positive: ○ ○ ○ ○

Specificity: 97% Sensitivity: 25% + Likelihood Ratios: 8.3 -Likelihood Ratio: 0.77

Chronopoulos E, Kim TK, Park HB, Ashenbrenner D, McFarland EG. Diagnostic value of physical tests for isolated chronic acromioclavicular lesions. Am J Sports Med. 2004 Apr-May;32(3):655-61.

Shoulder Impingement Syndrome

Shoulder Impingement Syndrome • Pain lateral aspect of the arm down to the deltoid tuberosity. – Hypertonic Saline Injections in subacromial space • Gerber C, Galantay RV, Hersche O. The pattern of pain produced by irritation of the acromioclavicular joint and the subacromial space. J Shoulder Elbow Surg. 1998 JulAug;7(4):352-5.

Shoulder Impingement Testing

Shoulder Impingement Testing • Painful Arc Test

• Sensitivity 53% Specificity 76%

• Hawkins-Kennedy Test

• Sensitivity 79% Specificity 59%

• Neer Test

• Sensitivity 72% Specificity 60%

Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, Wright AA. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med. 2012 Nov;46(14):964-78. Hegedus EJ, Goode A, Campbell S, Morin A, Tamaddoni M, Moorman CT 3rd, Cook C. Physical examination tests of the shoulder: a systematic review with metaanalysis of individual tests. Br J Sports Med. 2008 Feb;42(2):80-92;discussion 92.

Test Cluster for Shoulder Impingement • Positive Hawkins-Kennedy Test • Painful arc (60-120 degrees) – During active shoulder elevation

• Positive Infraspinatus Test – Resisted ER with arm along the body – Pain and Weakness Present

•

All 3 positive: +LR of 10.56

– probability (95%) for any degree of impingement syndrome

• •

2 of 3 positive: +LR of 5.03 All 3 negative: -LR of .17

Park HB, Yokota A, Gill HS, El Rassi G, McFarland EG. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. J Bone Joint Surg Am. 2005 Jul;87(7):1446-55.

Rotator Cuff Tears

• Rotator cuff tears: 63% Paraplegic; 15% able bodied – 200 individuals (100 paraplegic; 100 able bodied) –

•

Akbar M, Brunner M, Balean G, Grieser T, Bruckner T, Loew M, Fürstenberg CH, Raiss P. Etiology of rotator cuff tears in paraplegic patients: a case-control study. J Shoulder Elbow Surg. 2012 Jan;21(1):23-8.

Rotator cuff tears in 49%; 20% Unilateral; 29% Bilateral – –

MRI of 317 individuals with paraplegia Akbar M, Brunner M, Balean G, Grieser T, Bruckner T, Loew M, Raiss P. A crosssectional study of demographic and morphologic features of rotator cuff disease in paraplegic patients. J Shoulder Elbow Surg. 2011 Oct;20(7):1108-13.

Tests for Rotator Cuff Tear • Lateral Jobe Test –

• •

Lasbleiz S, Quintero N, Ea K, Petrover D, Aout M, Laredo JD, Vicaut E, Bardin T, Orcel P, Beaudreuil J. Diagnostic value of clinical tests for degenerative rotator cuff disease in medical practice. Ann Phys Rehabil Med. 2014 Jun;57(4):228-43. Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, Wright AA. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with metaanalysis of individual tests. Br J Sports Med. 2012 Nov;46(14):964-78. Gillooly JJ, Chidambaram R, Mok D. The lateral Jobe test: A more reliable method of diagnosing rotator cuff tears. Int J Shoulder Surg. 2010 Apr;4(2):41-3.

• Supraspinatus and Infraspinatus – External Rotation Lag Sign • Sensitivity of 46-98% Specificity 72-98%

– Drop Arm Sign

• Sensitivity of 10-73% Specificity 72-98%

• Teres Minor

– Hornblower’s Sign

• Sensitivity of 100% Specificity 93%

Jain NB, Wilcox RB 3rd, Katz JN, Higgins LD. Clinical examination of the rotator cuff. PM R. 2013 Jan;5(1):45-56.

Tests for Rotator Cuff Tear • Subscapularis – Lift-off Test (and Lag Sign) • Sensitivity of 17-100% Specificity 60-98%

– Belly Press Test

• Sensitivity of 40-43% Specificity 93-98%

– Belly-off Sign

• Sensitivity of 14-86% Specificity 91-95%

– Bear Test

• Sensitivity of 60% Specificity 92%

Jain NB, Wilcox RB 3rd, Katz JN, Higgins LD. Clinical examination of the rotator cuff. PM R. 2013 Jan;5(1):45-56.

Test Cluster for Rotator Cuff Tear • Painful arc (60-120 degrees) – During active shoulder elevation

• Positive Infraspinatus Test – Resisted ER with arm along the body – Pain and Weakness Present

• Drop Arm Sign

• Combination of tests: probability of 91% for fullthickness rotator cuff tears. Park HB, Yokota A, Gill HS, El Rassi G, McFarland EG. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. J Bone Joint Surg Am. 2005 Jul;87(7):1446-55.

Tests for Rotator Cuff Tear

Long Head of Biceps • Anterior Shoulder Pain • Pain upon palpation

• Speed Test • Yergason’s Test •

•

Jain NB, Wilcox RB 3rd, Katz JN, Higgins LD. Clinical examination of the rotator cuff. PM R. 2013 Jan;5(1):45-56. Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, Wright AA. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med. 2012 Nov;46(14):964-78.

Glenohumeral Arthritis • Pain, loss of motion, decreased function. • Worse with activity; better with rest. – Davies et al. The Shoulder: Physical Therapy Patient Management Utilizing Current Evidence. 2006.

• X-ray confirmation

Scapula Dyskinesis

Scapula Dyskinesis • An alteration in the normal position or motion of the scapula during coupled scapulohumeral movements. • Often is caused by injuries that result in the inhibition or disorganization of activation patterns in scapular stabilizing muscles. • Causative mechanisms such as compromised anatomy (i.e. injury), muscle tightness, and scapular muscle weakness can contribute to the apparent dysfunction. • Scapular dyskinesis is frequently identified in impingement syndrome and rotator cuff disease. • Kibler WB, Ludewig PM, McClure PW, Michener LA, Bak K, Sciascia AD. Clinical implications of scapular dyskinesis in shoulder injury: the 2013 consensus statement from the 'Scapular Summit'. Br J Sports Med. 2013 Sep;47(14):877-85. • Kibler WB, Sciascia A, Wilkes T. Scapular dyskinesis and its relation to shoulder injury. J Am Acad Orthop Surg. 2012 Jun;20(6):364-72. • Lin JJ, Hsieh SC, Cheng WC, Chen WC, Lai Y. Adaptive patterns of movement during arm elevation test in patients with shoulder impingement syndrome. J Orthop Res. 2011 May;29(5):653-7.

2 Excellent References

•

Jain NB, Wilcox RB 3rd, Katz JN, Higgins LD. Clinical examination of the rotator cuff. PM R. 2013 Jan;5(1):45-56.

•

Myer C, Hegedus EJ, Tarara DT, Myer DM. A user's guide to performance of the best shoulder physical examination tests. Br J Sports Med. 2013; 47 (14) 903-907.

Not included in this lecture •

Due to brevity of lecture time, in depth analysis of the evidence on differential diagnosis and physical examination of the following:

• • • • • • • • • • • • • • • • •

CVA (stroke) TBI Pediatric shoulder complex Neuropathic Pain SLAP Lesions Frozen shoulder Posterior/Internal Impingement Axillary Nerve (shoulder dislocation) Long Thoracic (winging scapula) CN XI (Deltoid atrophy) Severe Spastic Hemiplegia,Tetraplegia Brachial Plexus Injury Suprascapular Nerve Entrapment Thoracic Outlet Syndrome Bursitis vs. Tendinitis vs. Tendinosis Cervical Myelopathy Post-op surgery –

Acromioplasty, Rotator Cuff repair, SLAP repair, Bankart Repair,Total Shoulder Replacement

Imaging of the Shoulder • Radiography (X-Ray) –

Medina GI, Nascimento FB, Rimkus CM, Zoppi Filho A, Cliquet A Jr. Clinical and radiographic evaluation of the shoulder of spinal cord injured patients undergoing rehabilitation program. Spinal Cord. 2011 Oct;49(10):1055-61.

• Computed Tomography (CT Scan) • Magnetic Resonance Imaging (MRI) –

Alves AP, Terrabuio Junior AA, Pimenta CJ, Medina GI, Rimkus Cde M, Cliquet Júnior A. Clinical assessment and magnetic resonance imaging of the shoulder of patients with spinal cord injury. Acta Ortop Bras. 2012;20(5):291-6.

Diagnostic Ultrasound • Emerging area for Therapists • Direct Access? • Assigning a clinical diagnosis as therapists?

– –

–

Brose SW, Boninger ML, Fullerton B, McCann T, Collinger JL, Impink BG, Dyson-Hudson TA. Shoulder ultrasound abnormalities, physical examination findings, and pain in manual wheelchair users with spinal cord injury. Arch Phys Med Rehabil. 2008 Nov;89(11):2086-93. Collinger JL, Fullerton B, Impink BG, Koontz AM, Boninger ML. Validation of grayscale-based quantitative ultrasound in manual wheelchair users: relationship to established clinical measures of shoulder pathology. Am J Phys Med Rehabil. 2010 May;89(5):390-400. Bonninger current study 2014.

Manual Exam and Imaging • Dinnes J, Loveman E, McIntyre L, Waugh N. The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review. Health Technol Assess. 2003;7(29):iii, 1-166.

• Clinical examination by specialists can rule out the presence of a rotator cuff tear!

• MRI or ultrasound could equally be used for detection of full-thickness rotator cuff tears, although ultrasound may be better at picking up partial tears. • Ultrasound also may be more cost-effective in a specialist hospital setting for identification of fullthickness tears.

“This is all great stuff…… but aren’t SCI patients’ shoulders different?”

ASIA Exam • Inherent in the ASIA Exam itself is solid evidence of what motor levels are intact.

ASIA UE Motor Exam Findings  Upper ○ C5 ○ C6 ○ C7 ○ C8 ○ T1

Extremity Key Muscles: = Elbow Flexors (Biceps) = Wrist Extensors = Elbow Extensors (Triceps) = Finger Flexors (Grip) = 5th Finger Abduction

 Not included in ASIA UE Motor Exam but important to MD’s and Therapists functionally: Deltoid, Rotator Cuff, Scapula Stabilizers, Pec’s, Trunk.

C5 Intact Muscles • Cervical Paraspinals • Diaphragm

• Trapezius • Deltoid

• Biceps • Brachialis • Brachioradialis

• Rhomboids • Serratus Anterior (partially innervated) • Rotator Cuff (partially innervated)

C6 Intact Muscles • Same as C5, but now have the following: • Clavicular Pectoralis • Supinator • Extensor Carpi Radialis (Longus and Brevis)

• Serratus Anterior • Rotator Cuff (fully innervated) • Latissimus Dorsi

C7, C8, T1 Intact Muscles • C7 now have Triceps • C8 now have Grip (hand function) • T1 (considered full hand function)

T2 and Below Intact Muscles At T2 ASIA: Fully Intact UE Musculature However don’t forget Trunk control •

Functional levels improve as progressive Trunk control (Abdominals and Erector Spinae) and strength improves.

• Eg. Patient with T12 Paraplegia will have significantly more trunk control than T2

Paraplegia.

•

Gagnon D, Verrier M, Masani K, Nadeau S, et al. (2009). Effects of trunk impairments on manual wheelchair propulsion among individuals with a spinal cord injury: A brief overview and future challenges. Topics in Spinal Cord Injury Rehabilitation 15(2):59-70.

Importance of incorporating EBP shoulder examination techniques when evaluating individuals in a seating clinic

Manual Wheel Chair Selection • Then……..

• Current

Ultralight vs. Folding Wheelchair • ZRA®

• Veloce®

Pushrim Performance • The Natural-Fit®

• The Surge®

Manual Assist add ons • Wijit®

• Evo®

Manual add on to improve performance • FreeWheel®

Power assist add on feature • e-motion®

• Xtender®

Power add on products

Scooters and basic power mobility

Complex power mobility

Standing Feature

Sports and Recreation

Sports and Recreation

Other Considerations • • • •

Level of injury Age Weight/body habitus Comorbidities:

– level of fitness, cardiovascular, previous shoulder issues

• Overall Function: – – – – – – –

• • • •

Complete LE loss UE Function Ability to stand/ambulate Trunk control Ability to transfer ADL’s and IADL’s Ability to perform weight shifts for pressure relief (redistribution)

Geographical region: city, hills, rural terrain Home Setting: space considerations (power chair) Transportation: vehicle Work, school, recreation activities

Adjunct to Seating • As Clinicians you can’t just stop at ideal wheelchair Rx and think you have solved the problem fully! • You must follow up with preservation Rx: – – – – – –

Posture correction Flexibility Strengthening Proper cardiovascular conditioning Mobility Training: Transfers, Pressure Relief, W/C Skills ADL and IADL adaptive strategies

• If you are not a PT or OT, please refer to PT and OT to address the preservation components.

3 Key Therapy Interventions of a Shoulder Preservation Program

• Posture • Flexibility • Strengthening

Super 3 Posture Exercises Combat the anterior tightness and posterior “over-stretched weakness”

• Cervical Retractions • Scapula Retractions • Backward Shoulder Rolls • Using Mirror for biofeedback • “Super 4”: Scapula Retraction with Depression

Flexibility of Key Musculature • Stretching needs to focus on specific anterior musculature (contributors of imbalance):

• Pectoralis (Major and Minor) • Shoulder Internal Rotators • Elbow Flexors • Upper Trapezius

Strengthening

“Reverse the anterior dominant shoulder!” • Start in acute rehab! • Target Posterior Musculature:

• Supraspinatus • Infraspinatus and Teres Minor • Middle Trapezius and Rhomboids • Lower Trapezius • Serratus Anterior

Supraspinatus • Prone Full Can (in Scaption)

– Greatest amount of EMG (fine wire) activity for Supraspinatus and Posterior Deltoid.

• Full Can (in Scaption) to 90°

– Greatest amount of EMG (fine wire) activity for Supraspinatus and less Deltoid – Minimizes humeral head superior migration – Allows clearance of greater tuberosity (ER of Humerus).

• • • • •

Reinold MM, Escamilla RF, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. J Orthop Sports Phys Ther. 2009 Feb;39(2):105-17. Reinold MM, Macrina LC, Wilk KE, Fleisig GS, Dun S, Barrentine SW, Ellerbusch MT, Andrews JR. Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises. J Athl Train. 2007 Oct-Dec;42(4):464-9. Reinold MM, Wilk KE, Fleisig GS, Zheng N, Barrentine SW, Chmielewski T, Cody RC, Jameson GG, Andrews JR. Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises. J Orthop Sports Phys Ther. 2004 Jul;34(7):385-94. Ekstrom RA, Soderberg GL, Donatelli RA. Normalization procedures using maximum voluntary isometric contractions for the serratus anterior and trapezius muscles during surface EMG analysis. J Electromyogr Kinesiol. 2005 Aug;15(4):418-28. Ekstrom RA, Donatelli RA, Soderberg GL. Surface electromyographic analysis of exercises for the trapezius and serratus anterior muscles. J Orthop Sports Phys Ther. 2003 May;33(5):247-58.

Infraspinatus and Teres Minor • Shoulder External Rotation

(with towel roll)

– More focused EMG activity of Infraspinatus – Decreased compensatory activity of Deltoid

• Side-lying ER (with towel roll)***

– Greatest amount of EMG: Infraspinatus and Teres Minor. – Enhances ratio of lower to upper trapezius activity – – – – –

Reinold MM, Escamilla RF, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. J Orthop Sports Phys Ther. 2009 Feb;39(2):105-17. Bitter NL, Clisby EF, Jones MA, Magarey ME, Jaberzadeh S, Sandow MJ. Relative contributions of infraspinatus and deltoid during external rotation in healthy shoulders. J Shoulder Elbow Surg. 2007 Sep-Oct;16(5):563-8. Cools AM, Dewitte V, Lanszweert F, Notebaert D, Roets A, Soetens B, Cagnie B, Witvrouw EE. Rehabilitation of scapular muscle balance: which exercises to prescribe? Am J Sports Med. 2007 Oct;35(10):1744-51. Reinold MM, Macrina LC, Wilk KE, Fleisig GS, Dun S, Barrentine SW, Ellerbusch MT, Andrews JR. Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises. J Athl Train. 2007 Oct-Dec;42(4):464-9. Reinold MM, Wilk KE, Fleisig GS, Zheng N, Barrentine SW, Chmielewski T, Cody RC, Jameson GG, Andrews JR. Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises. J Orthop Sports Phys Ther. 2004 Jul;34(7):385-94.

Middle Trapezius and Rhomboids • Prone Row –

High EMG Activity

–

High EMG Activity

• Mid and Low Rows • Scapula retraction – –

• • • • • • • •

(progression→ resistance)

Increased Supraspinatus strength potential Increases width of subacromial space

Kibler WB, Sciascia A, Wilkes T. Scapular dyskinesis and its relation to shoulder injury. J Am Acad Orthop Surg. 2012 Jun;20(6):364-72. Reinold MM, Escamilla RF, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. J Orthop Sports Phys Ther. 2009 Feb;39(2):105-17. Bitter NL, Clisby EF, Jones MA, Magarey ME, Jaberzadeh S, Sandow MJ. Relative contributions of infraspinatus and deltoid during external rotation in healthy shoulders. J Shoulder Elbow Surg. 2007 Sep-Oct;16(5):563-8. Cools AM, Dewitte V, Lanszweert F, Notebaert D, Roets A, Soetens B, Cagnie B, Witvrouw EE. Rehabilitation of scapular muscle balance: which exercises to prescribe? Am J Sports Med. 2007 Oct;35(10):1744-51. Reinold MM, Macrina LC, Wilk KE, Fleisig GS, Dun S, Barrentine SW, Ellerbusch MT, Andrews JR. Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises. J Athl Train. 2007 OctDec;42(4):464-9. McCabe RA, Orishimo KF, McHugh MP, Nicholas SJ. Surface electromygraphic analysis of the lower trapezius muscle during exercises performed below ninety degrees of shoulder elevation in healthy subjects. N Am J Sports Phys Ther. 2007 Feb;2(1):34-43. Myers JB, Pasquale MR, Laudner KG, Sell TC, Bradley JP, Lephart SM. On-the-Field Resistance-Tubing Exercises for Throwers: An Electromyographic Analysis. J Athl Train. 2005 Mar;40(1):15-22. Reinold MM, Wilk KE, Fleisig GS, Zheng N, Barrentine SW, Chmielewski T, Cody RC, Jameson GG, Andrews JR. Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises. J Orthop Sports Phys Ther. 2004 Jul;34(7):385-94.

Lower Trapezius • Prone Full Can

– High EMG and alignment of muscle fibers with movement

• Bilateral External Rotation

– Excellent ratio of lower vs. upper trap activity – Bonus of Infraspinatus and Teres Minor strengthening

• • • •

• • •

Reinold MM, Escamilla RF, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. J Orthop Sports Phys Ther. 2009 Feb;39(2):105-17. Bitter NL, Clisby EF, Jones MA, Magarey ME, Jaberzadeh S, Sandow MJ. Relative contributions of infraspinatus and deltoid during external rotation in healthy shoulders. J Shoulder Elbow Surg. 2007 Sep-Oct;16(5):563-8. Cools AM, Dewitte V, Lanszweert F, Notebaert D, Roets A, Soetens B, Cagnie B, Witvrouw EE. Rehabilitation of scapular muscle balance: which exercises to prescribe? Am J Sports Med. 2007 Oct;35(10):1744-51. Reinold MM, Macrina LC, Wilk KE, Fleisig GS, Dun S, Barrentine SW, Ellerbusch MT, Andrews JR. Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises. J Athl Train. 2007 OctDec;42(4):464-9. McCabe RA, Orishimo KF, McHugh MP, Nicholas SJ. Surface electromygraphic analysis of the lower trapezius muscle during exercises performed below ninety degrees of shoulder elevation in healthy subjects. N Am J Sports Phys Ther. 2007 Feb;2(1):34-43. Myers JB, Pasquale MR, Laudner KG, Sell TC, Bradley JP, Lephart SM. On-the-Field Resistance-Tubing Exercises for Throwers: An Electromyographic Analysis. J Athl Train. 2005 Mar;40(1):15-22. Reinold MM, Wilk KE, Fleisig GS, Zheng N, Barrentine SW, Chmielewski T, Cody RC, Jameson GG, Andrews JR. Electromyographic analysis of the rotator cuff and deltoid musculature during common shoulder external rotation exercises. J Orthop Sports Phys Ther. 2004 Jul;34(7):385-94.

Serratus Anterior • Push-up with Plus • Dynamic Hug • Serratus Punch at 120° – High EMG activity with all – – – –

Andersen CH, Zebis MK, Saervoll C, Sundstrup E, Jakobsen MD, Sjøgaard G, Andersen LL. Scapular muscle activity from selected strengthening exercises performed at low and high intensities. J Strength Cond Res. 2012 Sep;26(9):2408-16. Reinold MM, Escamilla RF, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. J Orthop Sports Phys Ther. 2009 Feb;39(2):105-17. Ekstrom RA, Soderberg GL, Donatelli RA. Normalization procedures using maximum voluntary isometric contractions for the serratus anterior and trapezius muscles during surface EMG analysis. J Electromyogr Kinesiol. 2005 Aug;15(4):418-28. Ekstrom RA, Donatelli RA, Soderberg GL. Surface electromyographic analysis of exercises for the trapezius and serratus anterior muscles. J Orthop Sports Phys Ther. 2003 May;33(5):247-58.

What does this all mean?

Are you using the best available evidenced based practice for evaluation and management of the shoulder?

Clinical Thoughts • Given the high incidence of shoulder pain in individuals with Spinal Cord Injury who use wheelchairs as primary means of mobility:

• Improved examination and manual evaluation techniques help clinicians: • Recognize dysfunction earlier. • Prevent future problems. • Improve intervention strategies: – Seating and mobility. • Improve education of patients. • Create consistent best practice!

Anecdotal Implementation • • • • • • • •

Paraplegia Tetraplegia Central Cord Multiple Sclerosis CVA TBI Brachial Plexus Impingement Syndrome

• Rotator Cuff Repair • Total Shoulder Replacement • Dislocation • Subluxation • Biceps Tendinitis • SLAP • Proximal Humeral Fractures • Pediatrics

Just when you thought we were all done • We added a whole new complexity to the equation. • 1 more reason to emphasize strengthening the shoulder in SCI.

Questions?

Thank You! [email protected] [email protected]