Craig J. Newsam, D.P.T. Pathokinesiology Laboratory Rancho Los Amigos National Rehabilitation Center

1. Development of a Standardized and Individualized Intervention Protocol for the STOMPS Project Management of Shoulder Pain in Persons with SCI Craig J. Newsam, D.P.T. Pathokinesiology Laboratory Rancho Los Amigos National Rehabilitation Center

2. LEAD INVESTIGATORS Sara Mulroy, PhD, PT Bryan Kemp, PhD Pathokinesiology Lab Center for Aging with Disability RLANRC RLANRC PROJECT COORDINATOR Dee Gutierrez, PT Assessment Dee Gutierrez, PT Lisa Lighthall Haubert, PT Valerie Eberly, PT Intervention Craig Newsam, PT Jennifer Whitney, PT

3. Research Program Development from a Clinical Perspective • Identification of the problem • Identification of potential cause • Development of treatment program

4. Living with SCI • Life expectancy approaches that of non-disabled population • 20 y.o. non-disabled = 58 additional years • 20 y.o. with paraplegia = 46 additional years • 20 y.o. with tetraplegia = 42 additional years • 40% of people with SCI are over age 46 National SCI Database www.spinalcord.uab.edu 2004

5. Shoulder Pain with SCI % < 55 - 910 - 14 15 - 19> 20 Years since onset Sie et al., 1992

6. Shoulder Pathology in SCI • The most common causes of shoulder pain in persons with chronic SCI are musculoskeletal, particularly overuse injuries to the rotator cuff. • Impingement syndrome • Rotator cuff tendinitis • Supraspinatus tendinitis • Bicipital tendinitis • Subacromial bursitis Dyson-Hudson & Kirshblum, 2004

7. Weight-bearing tasks transfer forces to shoulder via the humerus • Significant risk for impingement of subacromial structures The Weight-Bearing Shoulder • Shoulder designed for locating the hand in the environment

8. Load to Failure Tendon Thickness Rotator Cuff Tendinopathy • Rat shoulder model • Trauma combined with Overuse • Greater tendon thickness • Reduced load to failure Soslowsky et al., 2002

9. Functional Demands Associated with Shoulder Pain in SCI • Manual WC Propulsion • Pressure Relief Raise • Depression Transfers • Overhead Activities

10. Demands of Manual WC Propulsion • Highly repetitive • Weight bearing • Bilateral

11. Shoulder Motion • Initial contact with humerus in extension, abduction & internal rotation • Loading mechanics create potential for impingement Newsam et al., 1999

12. Shoulder Joint Reaction Forces • Predominantly superior and posterior during push phase • Superior force increases > 3-fold during FAST and GRADED propulsion superior posterior 0 20 40 60 80 100 % PUSH Kulig et al., 1998

13. Mulroy et al., 1996 PUSH Phase Muscles

14. PUSH Phase Muscles • Generate propulsion force & protect G-H joint • Humeral Flexors • Pectoralis Major & Anterior Deltoid • Rotator Cuff • Infraspinatus & Supraspinatus • Scapular Muscles • Serratus Anterior Mulroy et al., 1996

15. Mulroy et al., 1996 RECOVERY Phase Muscles

16. RECOVERY Phase Muscles • Decelerate arm & reposition hand • Humeral Elevators • Middle & Posterior Deltoid • Rotator Cuff • Subscapularis & Supraspinatus • Scapular Muscles • Middle Trapezius (Rhomboid) Mulroy et al., 1996

17. Demands of Depression Transfers & Raises • High Superior shoulder forces – 50% of body weight • High muscle intensity with prolonged duration • Low repetition

18. Depression Transfers & Raises Latissimus Dorsi & Pectoralis Major elevate trunk & protect G-H joint Reyes et al., 1995 Perry et al., 1996

19. Depression Transfers & Raises • Weakness or fatigue threatens • G-H joint integrity

20. Infra Subscap Supra Depression Transfer –LOW Paraplegia N = 12 % MMT Perry et al., 1996

21. Risk Factors for Shoulder Pain in SCI Modifiable Non-Modifiable Age Posture ROM Duration of SCI SHOULDER PAIN Body Mass Anatomy Muscle strength UE Trauma Functional Demands Functional Demands

22. Homogenous population Global Clinical Program Attention Control STOMPS Protocol Design Recruitment Screening & Pre-assessment Randomized Exercise/Optimization Education Postassessment

23. Enrollment Criteria • EXCLUSION • Steroid injection in past 4 months • Surgery in past year • RA, CRPS, Adhesive capsulitis • Complete RC tear INCLUSION • Paraplegia from SCI • Shoulder pain • Propel manual WC > 50% • 5 years post onset of SCI

24. Recruitment Challenges • Redefining “PAIN” for the person with chronic SCI • What is “EXERCISE” as it relates to shoulder pain? • Not just any UE weight training • Mobility is not exercise • Previous therapy experiences

25. Education Program – 12wks • 1-hr educational video on shoulder care with handout • APTA shoulder education pamphlets • Question & Answer session • Keep log to record any changes that affect shoulder pain

26. Standardized and Individualized Intervention Protocol • Standardized • Content • Relative exercise intensity • Individualized • Exercise modification if needed for balance, elbow & wrist pain • Method of transfer / WC propulsion style

27. Exercise & Movement Optimization Program – 12wks • Stretching • Shoulder / Rotator Cuff Strengthening • Training / Instruction in Movement Performance • WC Propulsion • Transfers & Raises

28. Standardized Stretching Program • Anterior Thoracic • Posterior Capsule • Upper Trapezius

29. Standardized Strengthening Program • Home Exercise Program • 3 days per week • DuraBand® elastic bands & free weights • Performed from a wheelchair • Based on guidelines for hypertrophy and endurance from ACSM & NSCA

30. Standardized Strengthening Program • Program Goals • Shoulder pain vs. visible muscle mass • 2 hypertrophy exercises (3 sets of 8 reps) • 2 endurance exercises (3 sets of 15 reps)

31. Hypertrophy Exercise – 8RM Diagonal pull-downs • Pectoralis major • Propulsion power • Active in transfers • Non-weight bearing

32. Hypertrophy Exercise – 8RM External rotation • Infraspinatus • PUSH phase of WC propulsion • Active in transfers

33. Endurance Exercise – 15RM Scaption • Supraspinatus • Active in both PUSH & RECOVERY phase of WC propulsion

34. Endurance Exercise – 15RM Scapular Retraction • Rhomboids • RECOVERY phase of WC propulsion at 62% PC duration

35. Movement Optimization • Transfers • Modify height of transfer surface • Hand & arm position • WC Propulsion • Propulsion technique • Energy conservation

36. Thank You Pathokinesiology Laboratory