A spinal cord injured individual is forced to rely on their upper extremities for their weight bearing activities such as transfers, mobility needs, and ADLs using limbs that were designed to place hands in space (Consortium for Spinal Cord Medicine 2005; Dalyan et al., 1999; Dyson-Hudson & Kirshblum 2004). Repeated use of the upper limb for weight bearing activities such as manual wheelchair propulsion, transfers, raised ischial pressure reliefs (weight shifts), and reaching from a seated position in the wheelchair in environments designed for nondisabled individuals places a great deal of stress on the bones, joints, and soft tissues of the shoulder complex. The structures of the upper limb are therefore at significant risk for overuse and subsequent injury (Dyson-Hudson & Kirshblum 2004). Pain in the early post injury period is typically due to increased demands on anatomically weakened muscles or muscle weakness induced because of deconditioning.
Upper limb pain is known to interfere with a wide range of functional activities, transfers, ambulation, pressure relief, and self-care (Curtis et al., 1995a, Dalyan et al., 1999); many individuals report alteration/cessation of activities critical to functional independence (Pentland & Twomey 1994; Sie et al., 1992). Shoulder pain may be functionally and economically equivalent to a higher level of lesion (Salisbury et al., 2003). Dalyan et al. (1999) reported that of individuals with upper limb pain, 26% needed additional help with functional activities and 28% reported limitations of independence. Subbarao et al. (1994) and Gerhart et al. (1993) found that individuals with SCI reported that their dependence in personal care assistance fluctuated with upper limb pain and was a major reason for functional decline. The Consortium for Spinal Cord Medicine (2005) has written clinical practice guidelines “Preservation of Upper Limb Function Following Spinal Cord Injury: A Clinical Practice Guideline for Health Care Professionals,” to address upper limb problems. Recent studies have also started to explore factors that relate to upper extremity pain (Barbetta et al., 2016).
In the subacute phase of rehabilitation, the strategies that were initiated during the acute phase of rehabilitation are continued (Field-Fote, 2009). Adjustments may be made to the approaches to rehabilitation, however, working towards the therapeutic goals to help persons with SCI achieve optimal functioning continues. Exercises to strengthen the upper limb during this phase of rehabilitation can include progressive increases to the resistance of weight to improve muscle strength (Field-Fote, 2009). Hand grasping and opening are also a focus of this phase of rehabilitation.
Table 9: Subacute Phase of Rehabilitation
Opening the hand to grasp for objects is often compromised after cervical SCI. Stahl etl al. (2015) hypothesized that persons with SCI demonstrate neuromuscular coordination strategies, allowing object-specific hand aperture scaling while reaching. This was tested with different sized objects and authors concluded that motor planning for aperture modulation is preserved despite the limitations on hand opening capacity and muscle co-activity (Stahl et al., 2015).
The increased use of the upper extremity has been associated with a higher occurrence of musculoskeletal pain among SCI injured individuals (Boninger et al., 2005). A retrospective chart review considered factors that are associated with musculoskeletal pain. This study found that women, tetraplegia, being over 41 years of age, exclusively using a wheelchair for locomotion, and being less than one-year post-injury were significantly related to the presence of musculoskeletal pain (Barbetta et al., 2016).
The following are the identified risk factors for the development of musculoskeletal pain (Barbetta et al. 2016):
- Gender – women.
- Compleness of injury- tetraplegia.
- Time of injury- persons less than one-year post-injury.
- Age – being over 41 years of age.
- Locomotion – exlusively using a wheelchair.
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). Cognitive-behavioural strategies have also been suggested to be beneficial among SCI injured individuals (Heutink et al., 2013).
As identified in the Consortium for Spinal Cord Medicine (2005) document, modification of task performance based on ergonomic analysis has been shown 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. 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 a series of recommendations regarding the upper limb. First, 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. Additionally, patients should have their function, ergonomics, equiptment and level of pain assessed at each perodic review. At this time other potential risk factors can also be addressed, such as changes in medical status, new medical problems, and changes in weight. Lastly, general housekeeping measures which can benefit the patient were identified as reducing the number of non-level transfers per day, assessing work related activities and re-evaluating their current exercise program.
The Consortium for Spinal Cord Medicine (2005), Sipski and Richards (2006), Campbell and Koris (1996), Dalyan et al. (1999), and Nichols et al. (1979), 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.
- 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.
- Further clinical and biomechanical research to improve the preventative measures and treatment methods of upper limb pain in SCI persons in order for them to maintain optimal functional status.
There is level 4 evidence (from one post-test study; Stahl et al., 2015) that among persons with chronic SCI motor planning for aperture modulation is preserved.
There is level 4 evidence (from one case series; Barbetta et al., 2016) that the presence of musculoskeletal pain is not necessarily related to lifestyle factors (such as BMI and mobility aid) but more of a function of other demographic factors (such as gender, age, and level of injury).
Preliminary reseach suggests that persons with SCI may preserve the ability to scale peak hand aperture with ball size objects while reaching, which may be due to distinct muscle coordination patterns including increased co-activity of flexors and extensors at the wrist.