Upper Extremity Wellness for Wheelchair Users

3/18/2014 Upper Extremity Wellness for Wheelchair Users Sara Kate Frye MS OTR/L ATP  Sara Kate has been an OT for almost 9 years. She has presente...
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Upper Extremity Wellness for Wheelchair Users

Sara Kate Frye MS OTR/L ATP 

Sara Kate has been an OT for almost 9 years. She has presented at MOTA, ASIA, and ASCIP conferences on topics related to spinal cord injury rehabilitation.

Formerly Kernan Hospital Largest provider of rehabilitation services in Maryland. 137 bed hospital serving individuals with SCI, TBI, CVA, general rehab as well as medical surgical services.

Sara Kate Frye,MS OTR/L ATP Toni Marken COTA/L

Toni Marken COTA/L Toni has been a COTA for over 20 years.  She has presented at MOTA and AOTA conferences on the topic 

of sexuality and the disabled.

Baltimore Adapted Recreation and Sports (BARS) 

 

Enhancing the quality of life, improving self-esteem, and promoting health and fitness of individuals with disabilities through the provision of accessible and affordable recreation and sports programs Toni and Sara Kate are on the executive board. Visit www.barsinfo.org to learn more

Frye & Marken AOTA 2014

• •

Introduction Who is experiencing UE pain? What diagnostic groups commonly use a wheelchair for mobility and are therefore at risk for UE overuse injuries?  How can OT’s look beyond ADL’s to promote functioning in all area’s of life?  



Objectives    

Discuss wheelchair factors predisposing patients to repetitive strain injuries Identify tasks that commonly lead to shoulder discomfort Complete a basic shoulder evaluation Discuss strategies for developing an effective stretching and strengthening program List pro’s and con’s of manual versus power wheelchair mobility

Common Diagnoses     

 Wrist

   

MS SCI RA Neuropathy/ chronic pain

Predisposing Factors for Upper Extremity Injuries

Wheelchair Strain on the UE  Fingers/Hand

Amputation CVA Post Polio CP Spina Bifida

Pre-existing Injuries Joint Laxity  Arthritis  Obesity  Age  

 Elbow  Shoulder

Hand and Wrist

Part 1: Functional Anatomy Review

Frye & Marken AOTA 2014





Shoulder Anatomy

Boney Anatomy and Prominences for Palpation 




AC joint

SC joint

Spine of Scapula

Long head of biceps tendon

Acromion http://www.orthoandsportspt.com/Injuries-Conditions/Shoulder/ShoulderAnatomy/a~361/article.html


Muscular Attachments


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Superficial Musculature

Glenohumeral Joint 

Sub Acromial Space

Labrum – fibrocartilage that covers Glenoid and deepens Glenoid Biceps Tendon – inserts on superior portion of labrum and assists in humeral head depression and shoulder flexion

Dynamic Stabilization Deltoid


tendon passes through here Long Head of Biceps passes through as well Space is lacking here = impingement




Humeral Head Head of Biceps Depresses Humeral Head



Deltoid influence on humerus

Scapulohumeral Rythmn  2:1

ratio of how much motion happens between the:  Glenohumeral Joint : Scapula


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SGHL Glenohumeral Ligament  Joint- Horizontally oriented  Assists in preventing inferior translation of humeral head in resting position  Assists in preventing posterior translation with flexion and IR


 Superior

Medial Glenohumeral Ligament  Oriented in a lateral and inferior direction  Assists in preventing anterior translation 



IGHL  Inferior

Glenohumeral Ligament  Hammock with anterior and posterior bands being the borders of the axillary pouch “aka” hammock  Loose with arm resting and becomes taught with elevation  Assists in preventing anterior translation (90/90 position) and posterior portion limits posterior translation

Part 2: Common UE Overuse Diagnosis


Common Upper Extremity Overuse Diagnoses Carpal Tunnel Syndrome  Medial and Lateral Epicondylitis  Bicipital Tendinosis  Shoulder Pathologies  Bursitis  Arthritis 

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Carpal Tunnel Syndrome •

Tissues (synovium) surrounding the flexor tendons in the wrist swell and put pressure on the median nerve. Symptoms: numbness, tingling and pain.



Medial Epicondylitis   

Inflammation of the common flexor tendon Pain may spread to forearm and wrist Not just caused by golfing

Bicipital Tendinosis 

 

Inflammation of the long head of the biceps tendon Most commonly due to over head lifting Usually seen with other shoulder problems

Lateral Epicondylitis Inflammation of the extensor tendons Repetitive injury, not just tennis  ECRB (stabilizes wrist when arm is straight) most common tendon involved  

Shoulder Pathologies    

Shoulder tendinosis Rotator cuff tear Impingement Instability

Shoulder Tendinosis

Rotator Cuff Tears

Rotator cuff tendons becomes irritated and inflamed.  "rotator cuff tendinosis" is often associated with shoulder bursitis.

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  

One or more of the rotator cuff tendons is torn. Degenerative/acute Full-thickness/partial Supraspinatus most common.



Impingement 


The acromion can rub against the tendon and the bursa, causing irritation and pain. “Impingement syndrome”= tendinitis and bursitis

Arthritis 

 

Frequent Treatments

Inflammation of the joint which will cause pain and stiffness. Caused by wear on the joint Destroys articular cartilage

Acromioclavicular and Glenohumeral joint

Surgery ??? 

A slippery structure that exists in places where tendons pass over bones Inflammation and swelling of the bursa

    

Rest- avoid activity, splint Ice Compression- counter force brace Elevation NSAID

   

Stretching Strengthening Steroid injection Surgery


Plan for immobility: Consider modifications that will be needed to life during recuperation.  Required


 DME  Time

for recovery

Frye & Marken AOTA 2014



UE Evaluation 

Part 3: Evaluation

    

History Pain Visual Inspection Posture Palpation Range of Motion

   

Scapular mobility Strength Functional status Special tests

Scapular Mobility

Assessing Joint Stability

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Shoulder Assessments


WUSPI  SPADI  Shoulder Rating Questionnaire  ASES 

15 item self report survey assessing shoulder pain in wheelchair users using visual 10 point analog scale Sample Item: During the past week how much shoulder pain did you experience when:  Transferring from a bed to a wheelchair

Nawoczenski, et al. (2006) Clinical trial of exercise for shoulder pain in chronic SCI. Physical Therapy 86(12) 1604-1617.

SPADI- Shoulder Pain and Disability Index  

0-10 Scale for shoulder tasks Can show reduction in shoulder symptoms over time Available online at http://www.tac.vic.gov .au/upload/SPI.pdf

Sample Item: Pain scale  How severe is your pain?  

At its worst? Reaching for something on a high shelf?

Sample Item- Disability scale  How much difficulty do you have?  

Putting on a shirt that buttons down the front? Removing something from your back pocket?

Shoulder Rating Questionnaire   

Adapted from orthopedic questionnaire Examines pain, daily activities, recreational/athletic activities, and work Sample Item: Considering all the ways you use your shoulder during daily personal and household activities (eg dressing, washing, driving, household chores), how would you describe your ability to use your shoulder? A. B. C. D. E.

Very severe limitation, unable Severe limitation Moderate Limitation Mild Difficulty No Difficulty

Nawoczenski, et al. (2006) Clinical trial of exercise for shoulder pain in chronic SCI. Physical Therapy 86(12) 16041617.

ASES – The American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form    

Assess shoulder pain and functional disability/ ADL impairment Self-evaluation Scoring shows that a lower score means greater pain and disability Sample item – Circle the number in the box to indicate your ability to do the following activities:

0= unable to do, 1=very difficult to do, 2=somewhat difficult, 3=not difficult 1. Put on a coat 2. Wash your back/do up a bra 3. Manage toileting

Special Tests Look at:  Carpal Tunnel Syndrome  Medial and Lateral Epicondylitis  Rotator Cuff Pathology  Impingement Syndrome  Biceps Pathology  Shoulder Instability

Richards, R. et al. (1994). A standardized method for assessment of shoulder function. J Shoulder Elbow Surgery, 3(6), 347-352.

Frye & Marken AOTA 2014



Carpal Tunnel Syndrome Thenar muscle wasting Tinel’s sign  Phalens sign 

Lateral Epicondylitis Test 

Cozen’s test

Medial Epicondylitis test

Mill’s test

Therapist applies force to supination and wrist extension while palpating medial epicondyle

Hawkins-Kennedy Test 

Neer’s Sign Maximal passive adduction with internal rotation while stabilizing scapula  Positive is pain at subacromial space 

Frye & Marken AOTA 2014

Evaluates impingement of supraspinatus tendon Examiner moves arm into internal rotation. Positive is pain at subacromial space

Supraspinatus Test   

Empty can positioning Resisted scaption Weakness or pain is a positive result (more weakness in empty can vs. full)



Infraspinatus Test

Drop Arm Test Assesses for rotator cuff pathology Examiner passively abducts the patient’s shoulder to 90 degrees and releases patient’s arm with instructions to slowly lower the arm. Test is positive if the patient is unable to lower his or her arm in a smooth, controlled fashion

Test for infraspinatus sprain  Patient presses into external rotation. Pain or weakness postive result.



External Rotation Lag Sign

Lift Off 

Bear Hug 

 

Teres Minor Pathology Arm to 90 degrees of scaption, flex elbow and apply pressure into internal rotation Pain or weakness considered positive sign

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Place hand on opposite shoulder, therapist attempts to lift hand

Belly Press 

Horn Blower’s Test

Place hand behind back and lift off

Patient presses hand into belly

Apprehension Test Therapist externally rotates arm to end range.  Positive result is apprehension or pain. 



Speed’s Test

Yergason’s Test

Biceps muscle or tendon pathology  Resisted eccentric movement for shoulder extension  Pain more significant with supination

Assesses ability of transverse humeral ligament to hold bicep tendon into bicipital groove  Arm at side, resisted supination


Part 4: Intervention Translating our Evaluation Findings Into A Treatment Program

The Therapist’s Toolbox  

   

Activity Modification Wheelchair Assessment/ Seating and Positioning Therapeutic Exercise Stretching Mechanical Lifts Transfer Boards

 

 

  

Frye & Marken AOTA 2014

PVA Guidelines

Gloves Manual, Power, and Power Assist Wheelchairs Pillows Tub Benches Raised Commode Seat/ BSC

Clinical practice guidelines and consumer guides. Available online at www.pva.org

Topics:  Initial assessment of acute injury  Ergonomics  Equipment Selection, Training and Environmental Adaptations  Exercise  Management of acute and subacute upper limb injuries and pain  Treatment of chronic musculoskeletal pain to maintain function



High Stress Activities    

Repetitive tasks Overhead Reaching Transferring Wheelchair Pushing

Activity Modification   

Floor Surfaces Vary Hand Grip Avoid positioning of impingement/ Avoid internal rotation during functional activities

  

Activity Modification 2  

Avoid extreme positions of the wrist Avoid reaching overhead


Frye & Marken AOTA 2014

Move objects and tasks between waist and shoulder height Use built up grips Use appropriate DME Ask for help


Transfers:  Use

a hand grip when possible instead of weight bearing onto a flat hand  Level Transfers  Vary the arm that leads; switch sides




Therapeutic Exercise

Evidence Based Practice

Balanced strengthening Target key muscles  Include both endurance and strength exercises  Get out of the wheelchair  


12 Week HEP showed decreased shoulder pain in intervention group vs. control group. Results maintained at 4 weeks. Program: Warm-up, stretching, and resistive shoulder exercise (Hypertrophy exercises- ER and diagonal extension with adduction) (Endurance exercises humeral elevation in scaption and scapular retraction)

(Mulroy et al 2011)

Evidence Based Practice

Evidence Based Practice

Results of STOMPS also found correlation between improved WUSPI scores Social Interaction Inventory (SII) and Subjective Quality of Life Scale (SQOL)  Reduced shoulder pain leads to improved social participation and quality of life

(Kemp et al 2011)

8 week customized exercise program completed every other day  Strength:

Middle and lower trap, serratus anterior, shoulder external rotators  Stretching: Upper trap, pectoralis, long head of bicep, posterior capsule

Results: Improvements in WUSPI and SRQ in intervention group (Nawoczenski et al 2006)

Key Muscles and Actions 

Lat 

Teres Major 

Teres Minor/ Infraspinatus

Subscapularis 

External rotation Internal rotation

Serratus Anterior 

Protracts shoulder/ upward rotates scapula


Middle Trap

Lower Trap

Extension/adduction/ internal rotation

Extension/adduction/ internal rotation

Key Muscle Groups for Therex

 

Adducts/downward rotates scapula Adducts scapula

External Rotators  Internal Rotators  Scapular Protraction  Scapular Retraction  Scapular Depression 

Depress/upward rotates scapula

Supraspinatus 


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Prone Therex

Postural Exercises


Backwards shoulder rolls  Chin tucks  Scapular retraction

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Should be included as part of daily routine



Upper Trap

Wrist flexion/Extension


Internal Rotation

Inferior Capsule

Posterior Capsule

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Bed Positioning

The Iron Cross

7th Inning Stretch!

Frye & Marken AOTA 2014



Finding the Right Wheelchair

Part 5: Wheelchair Ergonomics

Manual vs. Power Mobility 

Power      

Manual 

Increased cost Increased Maintenance Decreased transportability Increased need for accessibility May increase speed of mobility Decreased load on UE during mobility, pressure relief, and transfers

    

Decreased cost Easily transported Increased maneuverability Can be manually lifted over environmental obstacles Increased load on UE May help prevent weight gain

Wheelchair Fitting 

  

Frye & Marken AOTA 2014

Proper wheelchair seating and positioning as well as training on effective use is essential for preventing overuse syndromes Consider not only mobility, but daily activities… driving, terrain, ADL’s, accessibility, number of transfers per day

Power Assist Wheelchair  

Additional option to consider Benefits of manual wheelchair weight and portability with the assistance of power-assisted drive in the wheels

Thoughts? Rear wheel forward (without compromising stability) Proper height Trunk support Ultra-light weight preferred




Evaluating Propulsion Patterns

http://web.resna.org/conference/ proceedings/2007/StudentScienti fic/Mobility/Roche/Fig1Thumb.jpg

Good or Bad?

Good or Bad?

Power Wheelchair Tips Support the arms  Consider functional activities  What seat functions can reduce strain, and how can you justify them? 

 Tilt

Part 6: Case Studies

in space, seat elevation, recline

Frye & Marken AOTA 2014



Case Study 1 

Cindy is a 27 year old female with T4 ASIA A paraplegia. She presents to acute rehabilitation for increased shoulder pain resulting in decreased independence in ADL’s and transfers. She uses a lightweight rigid frame chair with a sling back for mobility. At home, her bathroom is not very accessible and she stair bumps in the morning to get upstairs to take a shower. She has also been completing her bowel program from a standard toilet. She transfers into the drivers seat of her Toyota to drive. She never uses a transfer board. She has 2 young children and her husband often travels for work. Upon eval she is noted to have shoulder pain consistent with shoulder impingement, weak scapular muscles, and a forward hunched posture with protracted shoulders.

Case Study 2 

Yvonne is a 39 year old woman who has bilateral PVD, she has a history of poor compliance with medical recommendations including smoking cessation. She lives with her daughter in a first floor apartment. She is admitted to a sub-acute rehab for bilateral heel ulcers and is unable to safely bear weight through her feet at this time.

Case Study 3 

Bob is a 52 year old with MS. He uses a scooter for mobility but is unable to tolerate sitting in the scooter for prolonged periods of time. After a recent exacerbation, Bob has experiences neck and shoulder pain and reports he has recently fallen at home when he was trying to get his coat out of the closet. Bob comes to outpatient OT for evaluation and treatment.


References 

Available upon request [email protected] or [email protected]

Frye & Marken AOTA 2014


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