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 presented at MOTA, ASIA, and ASCIP conferences on topics related to spinal cord injury rehabilitation.
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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
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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?
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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
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Forearm
Elbow
Shoulder Anatomy
Boney Anatomy and Prominences for Palpation
Scapula
Clavicle
Humerus
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
http://www.webmd.com/pain-management/picture-of-the-shoulder
Muscular Attachments
http://www.stretching-exercises-guide.com/shoulder-stretches.html
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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
Supraspinatus
tendon passes through here Long Head of Biceps passes through as well Space is lacking here = impingement
Rotator
Cuff
Depresses
Humeral Head Head of Biceps Depresses Humeral Head
Long
http://paragonphysio.blogspot.com/2012/02/anatomy-of-shoulder.html
Deltoid influence on humerus
Scapulohumeral Rythmn 2:1
ratio of how much motion happens between the: Glenohumeral Joint : Scapula
http://thegymcoach.wordpress.com/2010/01/01/super-tight-shoulders-we-must-look-at-other-factors
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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
MGHL
Superior
Medial Glenohumeral Ligament Oriented in a lateral and inferior direction Assists in preventing anterior translation
http://www.shoulderdoc.co.uk/patient_info/shoulder-anatomy.asp
http://www.shoulderdoc.co.uk/patient_info/shoulder-anatomy.asp
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
http://www.shoulderdoc.co.uk/patient_info/shoulder-anatomy.asp
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 •
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Tissues (synovium) surrounding the flexor tendons in the wrist swell and put pressure on the median nerve. Symptoms: numbness, tingling and pain.
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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.
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Impingement
Bursitis
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
BREAK
Plan for immobility: Consider modifications that will be needed to life during recuperation. Required
assistance
DME Time
for recovery
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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
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.
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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
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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)
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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.
ERLS
Subscapularis
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.
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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
TRY IT OUT
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
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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
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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
Thoughts?
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Move objects and tasks between waist and shoulder height Use built up grips Use appropriate DME Ask for help
Thoughts?
Transfers: Use
a hand grip when possible instead of weight bearing onto a flat hand Level Transfers Vary the arm that leads; switch sides
Thoughts?
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Therapeutic Exercise
Evidence Based Practice
Balanced strengthening Target key muscles Include both endurance and strength exercises Get out of the wheelchair
STOMPS
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
Rhomboids
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
Abduction
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Rickshaw
Prone Therex
Postural Exercises
Stretching
Backwards shoulder rolls Chin tucks Scapular retraction
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Should be included as part of daily routine
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Upper Trap
Wrist flexion/Extension
Chest
Internal Rotation
Inferior Capsule
Posterior Capsule
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Bicep
Bed Positioning
The Iron Cross
7th Inning Stretch!
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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
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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
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Thoughts?
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
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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.
Questions?
References
Available upon request
[email protected] or
[email protected]
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