AA

Elbow/Wrist and Hand Injuries

The prevalence of elbow pain and injury has been reported to be between 5-16% (Consortium for Spinal Cord Medicine 2005). Sie et al. (1992) found 15% and 16% rates of pain localized in the elbow region in persons with tetraplegia and paraplegia. Dalyan et al. (1999) in their study found 35% complained of elbow pain.

The prevalence of carpal tunnel syndrome is reported to be between 40-66% (Consortium for Spinal Cord Medicine 2005). There are four studies that found an association between length of time since injury and prevalence of carpal tunnel syndrome (Aljure et al. 1985; Gellman et al. 1988; Schroer et al. 1996; Sie et al. 1992). Some studies also found median nerve damage without clinical symptoms.

Table: Shoulder Treatment Interventions

Discussion

The most significant activities causing pain in the wrist and hand are reported to be propelling a wheelchair and doing transfers (Subbarao et al. 1994). Management of established upper limb pain is very difficult and thus prevention is critical. Evidence-based best practice standards have not been established for the medical, rehabilitative or surgical treatment of upper limb injuries in people with SCI. In addition, there is little consensus among health-care providers on the best treatment practices for upper limb injuries in the general population. In general, musculoskeletal upper limb injuries in the SCI population are managed in a similar fashion as the unimpaired population.

Outcome studies of surgical treatment in SCI also very limited. Two small studies report the outcome of rotator cuff repair – one showing relatively poor results (Goldstein et al. 1997) and another study showing relatively good outcomes (Robinson et al. 1993). Both studies recommend non-surgical approaches prior to surgical intervention. One randomized controlled trial found that supervised exercise produced results similar to arthroscopic surgery for patients with impingement syndrome (Brox et al. 1993), however; this study was not on SCI patients.

Exercise has been shown to reduce pain in a randomized controlled trial in which subtypes of pain were not reported (Hicks et al. 2003). Two studies found an association between restricted ROM and pain, reduced activity and/or injury (Ballinger et al. 2000; Waring & Maynard 1991). A study incorporating stretching into an exercise program for individuals who use manual wheelchairs found stretching exercises were associated with decreased reported pain intensity (Curtis et al. 1999).

One study demonstrated that acupuncture was no more effective than Trager Treatment in the treatment of shoulder pain (Dyson-Hudson et al. 2001). There are several studies that address the use of complementary or alternative medicine (CAM) with the spinal cord population, which is used at similar rates to the general population. It was reported that the most common reason CAM was used, was for dissatisfaction with conventional medicine for treatment of chronic pain (Nayak et al. 2001). The only CAM technique evaluated in the SCI population is acupuncture although studies do not provide conclusive evidence of effectiveness (Dyson-Hudson et al. 2001; Nayak et al. 2001; Rapson et al. 2003).

Psychological interventions among non-SCI individuals with chronic pain are popular and it has been suggested that selected approaches may be useful for those with SCI (Consortium for Spinal Cord Medicine 2005). Cognitive-behavioural strategies have been found to produce changes in pain experience, increase positive cognitive coping and appraisal skills and reduce pain behaviours (Morley et al. 1999). There are mixed results for the use of relaxation training for relief of chronic pain (Carroll & Seers 1998), which may also have secondary beneficial effects on muscle tension and emotional distress (Astin et al. 2002; Leubbert et al. 2001). Cognitive-behavioral interventions have not been subjected to controlled trials as to their effectiveness in the SCI population (Wegener & Haythornthwaite 2001).

As identified in the Consortium for Spinal Cord Medicine (2005) document, modification of task performance based on ergonomic analysis has been proven to reduce the incidence of upper limb pain and cumulative trauma disorders of the upper limb in various work settings (Carson 1994; Chatterjee 1992; Hoyt 1984; McKenzie et al. 1985). It is suggested that these same interventions can be used to prevent pain and injury in SCI. Although the number of studies linking activities of individual with SCI to injury may be small, the ergonomics literature provides a strong basis for evidence-based practice. Recently, Rice et al. (2013) studied the impact of a strict education protocol in the implementation of the clinical practice guideline “Preservation of Upper Limb Function Following Spinal Cord Injury” addressing the impact of an education protocol on transfer skills and wheelchair propulsion. The study demonstrated a positive effect on the importance of proper education in improving the quality of transfers and better wheelchair propulsion biomechanics as key elements in reducing the risk of shoulder injury and pain (Rice et al. 2013).

The Consortium for Spinal Cord Medicine (2005) Clinical Practice Guideline Preservation of Upper Limb Function published the following recommendations regarding the upper limb:

  • Both the spinal cord injured person and the clinician need to be educated about the prevalence of upper limb pain and injury and the potential impact of pain and possible means of prevention
  • Routinely assess the patient’s function, ergonomics, equipment and level of pain as part of periodic health review
  • Assessment of risk factors, changes in medical status, new medical problems, changes in weight
  • Reduce the number of non-level transfers per day
  • Assess work related activities
  • Re-evaluate current exercise program (strengthening, stretching, conditioning)

Dyson-Hudson et al. (2001) in a randomized controlled trial compared acupuncture treatment to Trager Psychosocial Integration performed by a certified Trager practitioner. The authors noted that trager therapy is a form of bodywork and movement re-education to induce relaxation and encourage the patient to identify and correct painful patterns. The theory is that chronically contracted muscles induced by stress led to pain (Dyson-Hudson et al. 2001). There was a significant effect over time for both treatment groups in reducing shoulder pain, but there was no difference between the two groups.

Curtis et al. (1999) in a randomized controlled trial and Hicks et al. (2003) studied the effectiveness of a six-month exercise and stretching protocol on shoulder pain experienced by wheelchair users. The data supported the effectiveness of this exercise and stretching protocol in decreasing the intensity of shoulder pain that was interfering with functional activity of wheelchair users.

The Consortium for Spinal Cord Medicine (2005), Sipski and Richards (2006), Campbell and Koris (1996), Dalyan et al. (1999), and Nichols et al. (1979), have identified the following as important areas of further research in the upper limb:

  • Research to validate and support the adoption of a standardized classification scheme with accompanying diagnostic procedures and criteria.
  • Research trials could include both primary prevention and treatment of acute and chronic pain.
  • Determine the best methods to treat existing painful shoulder lesions and prevent others so that these individuals are as pain free and independent as possible.
  • Further study is needed to elucidate the mechanisms of pain in this group and to establish why some patients who have pain early in rehabilitation continue to have pain at discharge and others do not.
  • Multicentre RCT of intervention are also needed to reduce the severity and impact of different subtypes of SCI pain.
  • Possible links between pain during rehabilitation and pain in long-term SCI.
  • Detailed investigation of the biomechanics of activities commonly performed by people with tetraplegia to enhance understanding of the stresses placed on the shoulder and the mechanical causes of shoulder pain.
  • Causes of shoulder pain in the acutely injured individual compared to the chronic spinal cord injured person.
  • Implementation of upper limb pain prevention and management programs for persons with SCI- acute and ongoing patient education about basic biomechanical principles on avoiding impingement and overuse
  • Managing the early signs of strain and overuse and knowledge of several alternative techniques of ADL.
  • Education and training in endurance and balanced strengthening of muscles acting around the shoulder and optimizing posture to achieve a normal alignment of shoulder, head, and the spine are critical for avoidance of injuries.
  • Ergonomically designed environmental changes and wheelchair, home and work modifications

Conclusion

There is level 1b evidence (from two randomized controlled trials; Hicks et al. 2003; Curtis et al. 1999) that a shoulder exercise and stretching protocol reduces the intensity of shoulder pain post SCI.

There is level 1b evidence (from one randomized controlled trial; Dyson-Hudson et al. 2001) that general acupuncture is no more effective than Trager therapy in reducing post-SCI upper limb pain.

  • Shoulder exercise and stretching protocol reduces post SCI shoulder pain intensity.

    Acupuncture and Trager therapy may reduce post-SCI upper limb pain.

    Prevention of upper limb injury and subsequent pain is critical.