[ Silence ] Hello, and welcome to the spinal cord injury forum. I'm Stephen Burns, medical co-director of the Northwest Regional Spinal Cord Injury System. The forums, the video recordings, and our online media content are made possible by a grant from the National Institute on Disability and Rehabilitation Research. Tonight's presentation on protecting your shoulders and staying active after spinal cord injury. Our speaker Kristin Kaupang, physical therapist in the Rehabilitation Medicine outpatient clinic at Harborview Medical Center. After the presentation, we'll have a question and answer session. Now, please welcome our speaker Kristin Kaupang. [ Applause ] Okay, thank you guys for coming tonight. I'm excited to be here. I am a physical therapist at Harborview like Dr. Burns says. I've been a therapist for 16 years now. The past 11 years, I've been working primarily in the neurological rehab both inpatient and outpatient. So dealing a lot with spinal cord injury and a lot with shoulder pain so it's definitely something I see pretty regularly, either daily or weekly in our clinic and I'm sure you guys deal with it daily or weekly at home yourself. So hopefully, today, I'll be able to give you some background, some review of the research, some ideas and some strategies on how you can really protect your shoulders and stay healthy not only, you know, today, but as you're aging with your spinal cord injury. So the objectives today, I want to-- at the end of the presentation, I would like to see you guys be able to recognize the changing function and impact on shoulders after spinal cord injury to be able to identify the key structures in the shoulder complex and strategies to protect the shoulder after spinal cord injury, to demonstrate basic stretching and strengthening exercises to facilitate preservation of shoulder function, and to demonstrate positions or environmental adaptations that will help to preserve your shoulder health. So as you all know, there's a lot of changing roles of all muscles after spinal cord injury. When you think about the spinal cord injury for a complete injury, you now have somebody that's relying completely on their upper extremities for what their legs use to do, that's a lot of pressure, a lot of weight on the shoulders which tend to be the joint that takes the brunt of that impact. For incomplete injuries, when you have somebody that has altered strength or altered sensation, they may use their muscles a little bit differently or it's a little bit less efficient so you're not doing them in the same pattern as you were used to doing the exercises or the activities before. And so you have these abnormal stresses on your shoulder. And over time, these abnormal stresses could potentially cause pain or could cause discomfort. And the shoulders themselves are an extremely flexible joint. With the ball and socket arrangement of the shoulder, it gives you really infinite number of directions of the shoulder you can move. You can see baseball pictures, you know, going a full windmill circle. And we think about the shoulder sometimes as sort of having this endless amount of range of motion which is great for function in some ways but it also allow-- it sort of precludes you to getting an injury or potentially sort of putting it at risk because there are so many ligaments, there are so many tendons, there are so many muscles that sort of go surrounding that shoulder capsule to keep it protected, that we really have to be careful not to push it to its end-ranges of motion all the time and not to always, you know, utilize that entire flexibility within the joint. The other interesting thing about the shoulder is that it's very dependent on the scapula or your shoulder blade as well as your trunk. So movements within the trunk are going to affect the shoulder and the ability to move your scapula has a huge impact on how you're moving your shoulder itself. So we'll talk a little bit about that relationship as we're going on. And as you know, paralysis mandates an increase demand on the shoulders not only in transfers but in sitting balance at times, carrying items or objects, propulsion of the wheelchair and pressure relief just to name a few of them. As many of you probably-- how many in the audience here have had shoulder pain at some point in their injury? So I think we've had-- that's probably pretty close to what the average-- closer to the 70 percent prevalence. You know, you're pretty close to three out of four spinal cord injury individuals who have shoulder pain in the duration of their spinal cord injury throughout their life. That's a really high percentage and that could be even higher. We don't really know how they're reporting all this. You could have minor shoulder pain that maybe the doctor didn't know about or they didn't get reported on to a study. So even the smallest amount of pain is something that you guys need to pay attention to or something we have to address early on to prevent it from getting any worse. It's been shown in the research that the incidence or the amount of shoulder pain increases over time after you have a spinal cord injury and then it also-- in 1991, one of the studies showed that it was the only factor that was identified with a lower quality of life score. So having shoulder pain made the individuals feel like they didn't have as good of a quality of life as if they didn't have shoulder pain and we're able to get around a little bit more. The study was in 1991 so there might be other studies that are no longer-- this might not be the unique feature anymore but it's definitely a pretty high priority, in the ability to do the things that you want to do throughout your day. So how do you protect and how do you preserve your shoulders? And you guys have probably heard lots of different strategies and lots of different techniques throughout your rehab, throughout outpatient, friends, family, you know, just a sort of going along with your daily activities. I'm going to go over four different areas today, or four different sort of topics and try to give you ideas within each of them that you could either modify part of your activity at home or give you ideas of how to be able to adapt things that you're doing right now. So the first category would be rest or stopping the use of the painful extremity, to modify the task performance, to modify the environment of the task being performed, and then to strengthen and to maintain flexibility. The last one will be the biggest one that we talked about and certainly more in my domain of being a physical therapist looking at strength and flexibility. So the first category of resting and stopping the use of a painful extremity, so it's pretty much impossible. As you guys know, everything that you do, you're using your shoulders. When you get out of bed, when you're rolling, when you're sitting, when you're able to transfer, it's almost impossible to stop complete use of the upper extremity unless you're going bed rest where you have a full caregiver support and that's not really all that practical for anybody and it may not be really an option for people. So partial rest, how could you decrease your activity to think about different ways that you could slowly sort of relax your shoulders or give them a break throughout the day? One will be decrease frequency of movements that cause pain. So if you know you have to reach for something in a cabinet and it takes you a while to position really close or really comfortably to be able to get that, get everything you need out of that cabinet at one time. Do it once, or plan or ahead, or you know, utilize your caregiver support for the task that you think are difficult for your shoulder or they may cause pain that you're able to get some help with. You also can use your non-dominant hand for any activity that you're capable of doing. So even the simple task of eating, say your right hand dominant and your right shoulder is the one that has quite a bit of pain, just taking a spoon in your left hand and trying to feed yourself with your left hand gives you a break with your right shoulder, it's one last thing that you have to do during the day that's impacting that shoulder. That's a pretty minor change, but could you do opening the door with your left hand versus your right hand if your, you know, right hand is-- or your right shoulder is a little bit injured or impaired. So thinking about the activities that you can actually change or alter or using your strengths to be able to switch-- to decrease the amount of pain in your shoulder. So positioning is a really important one as well, and I'm going to just sort of give a caveat. There's a couple pictures here that are recommended. These are from the Spinal Cord Injury Clinical Practice Guidelines that are dealing with preservation of upper extremity function. If you guys don't have a copy of the preservation of upper extremity function guidelines, it is on the website from the National Spinal Cord Injury Association. It's a great read, it's really important, and I think a lot of these pictures are coming from here. But they're not going to be ideal for everybody. These are going to be sort of like exactly what you are hoping to get towards but you may not be able to be completely on your back. You may not be able to be completely on your side. You're going to have to modify a little bit based on your injury and based on your comfort level and how you're doing. So when I think about positioning of the shoulder I bed, if you're lying on your back, if your arms are down by your side, you're in what I call internal rotation. So your arm is sort of rotated in, to the side like this. Once you're turned in, you close off the space of your shoulder. I like to call this, you know, this position of your shoulder, when I have my hand out, I consider this what I call a open packed position of the shoulder so I have more space for all the tendons, all the nerves, all the blood vessels coming through here. As soon as I rotate my shoulder in, I have less space and there's more chance of things sort of pinching. So sleeping with your hands rotated in is not a great position. How can you get closer to this open position? One of them is this position here that you see over on the right hand of your screen is having your arm behind you, but not all the way back because that's going to put a lot of stress on your shoulder. But put it a little bit on a pillow so you're able to get some support, you get a little bit of stretch through your shoulder while you're sleeping. That-- so hopefully, will help to sort of decrease the pain. If you're-- if this is your painful shoulder, then you may not be able to tolerate that position. Maybe you'd only be able to tolerate your arm1 out to the side a little bit, you know,1 and not completely all the way back.1 So you have to sort of modify, you know,1 where you're going based on your level of pain.1 The lower picture is another example.1 So, his right arm on the side is very similar to the right arm1 on the pillow here and then the other arm is just1 out to the side.1 Again, in a open position, opening up the shoulder joint1 versus closing the shoulder joint coming down here.1 Even this position with both hands1 out to the side would be better than both hands down here1 at your sides, 'cause you're keeping your shoulders open,1 you're getting nice flip flop or good nutrition for the joint.1 The question was, why wouldn't you want to have both arms up1 or both arms in this 90 degree position?1 There's no reason why you couldn't.1 Again, it's based on whether you're comfortable1 or whether you're able to tolerate that position1 and that helps to relieve some of the pressure1 in the shoulders, so yap, that will be fine.1 The question was if you have somebody sleeping next to you1 and you're not able to sleep in this sort of, you know,1 open position where you're going to be hitting the person next1 to you what would you do--1 what would be the next best alternative?1 You know, certainly you could come up here1 if you have enough space, it's better than being way1 out to the side but also just sort1 of getting your shoulder elevated just a little bit1 and supporting on a pillow would be better than, again,1 that close position at the shoulder.1 So for sleeping on your side, you can see here, you're going1 to have a pillow on your side for your upper arm1 so you're sort of hugging a pillow.1 And again, with the hugging of the pillow, you get opening1 in the shoulder joint, you don't have that closed position,1 you don't have it really nice and tight through here,1 you have it a little bit open, it's allowed1 to move a little bit easier.1 And you don't want to be completely on your lower arm.1 So a lot of people are really tender to sleep1 on a painful shoulder and you don't want1 to be sleeping directly on your shoulder,1 so perpendicular to the bed.1 You want to have a little bit of rotation so your shoulder is1 out a little bit so it's not stock underneath you, okay.1 So pillow on this side and then you can have a pillow1 to rest your arm on the opposite side as well.1 And you can see, and this is obviously a really important1 for pressure relief as well1 that you're changing position throughout the night,1 that also helps your shoulders.1 Keeping your shoulders in one position for eight hours1 in a row, you're going to wake up a little bit uncomfortable,1 I think everybody would wake up slightly uncomfortable1 if you're sort of stuck in one position the whole time.1 So if you can rotate every three to four hours,1 I think that's a good target to be able to change your position.1 On your stomach is another good position to rest.1 And again, you want to keep your shoulders1 in a open position not in a close position.1 So having your arms, you know, a little bit further away1 from your body and having one arm sort of up to the side here.1 Using pillows, using supports, whatever you can to sort1 of modify your sleeping environment.1 1 Okay, so again, when you're able to rest,1 positioning is still important.1 So sitting, we talked a little1 about this open pack position of your shoulders.1 Same thing with sitting, I don't want to be sitting1 with my arms crossed all the time or sort of tucked in,1 I'm keeping my shoulders in this tight position.1 Certainly, this is a very comfortable position1 for a lot of people.1 You rest your arms on a desk, you, you know,1 do a lot of things and, you know, in this position.1 But if you're able to, and it's not impacting your function,1 try to keep your arms out to the side,1 you keep a little bit better stretch,1 you keep your joint moving a little bit and you prevent it1 from getting into this pinched sort of state.1 The other thing that you can do while you're sitting is really1 think about your shoulder blades.1 As your shoulder blades are working,1 if you pull your shoulder blades together1 like you're pinching them together in the back.1 So squeezing your shoulders back, you're helping to open1 up that position of your shoulders.1 As soon as your body starts to hunch forward1 or your posture slumps, your shoulders getting1 that close position again1 and it's really hard to get them moving.1 For everybody that can right now, I want you guys1 to just slump in your chairs or slump down as much as you can.1 And then I want you to raise one arm.1 Okay, and now I want you to sit up with the best posture1 that you possibly have ever seen in your life1 and raise the same arm.1 It's a lot easier, right?1 So you get a lot more motion, you're able to sort of do more1 if you have good posture.1 So a good base of support is essential for shoulder function.1 If you're sitting slumped in your chair,1 if you don't have any good support or sort on your lumbar1 or your pelvis, you could easily decrease the amount1 of shoulder movement you have1 and cause your shoulders to work harder.1 So positioning is really important.1 If you haven't had, you know, an evaluation of your sitting1 and positioning, I think that would be an essential thing1 to make sure that you're optimizing that motion.1 1 So changing the task performance to reduce the forces1 on the shoulder joint, so transfer is obviously are one1 of the biggest things that you guys do1 that impacts your shoulders.1 And transfers are essential, you need to be able to get1 in another bed, you need to be able to get1 in and out of the car.1 Every sort of movement that you're doing could be--1 during a transfer is really putting a lot1 of weight on your shoulders.1 Your hand placement is very important with transfers.1 Do you guys know what I would say1 for the hand position, where would it be?1 Open [laughs], so almost everything is kind of becoming1 to this open position.1 So you don't want to do a transfer1 with your arms really rotated in because you have a chance1 of pinching sort of other structures that come1 into that anterior shoulder.1 So as much as you're able to, you want to rotate your hand1 out about 30 to 45 degrees before you do your transfer1 as you're doing.1 You're setting your position, you're allowing your shoulder1 to stay a little bit in a looser position.1 If you have shoulder pain, and you're doing transfers1 that are doing a lift up and over.1 And it hurts halfway through the motion1 and through all the rest of the motion.1 And another idea would be the use of sliding board1 and make smaller motions, be more efficient with your motions1 and not exacerbate that pain.1 You can sort of do a strategy to get yourself1 over just a little bit at a time.1 You want to avoid extreme positions.1 So if I'm doing a transfer and I'm reaching my arm way1 over here and then trying to push, you're going1 to put stress on that shoulder.1 Anything you can do to position your chair better,1 anything you can do to position your body better1 to allow yourself to sort of avoid1 that extreme motion is going to be important.1 The other thing that's being shown is you want to lead1 with your arm that's experiencing shoulder pain1 if you have pain, and if you're able to.1 If you're position or the environment sets it up.1 And the reason is, this radius anterior which is a muscle1 that does a lot of depression or sort1 of this lift motion is shown to have more force1 in the trailing arm than in the leading arm.1 So the leading arm does less work1 and there's less force applied through the shoulder1 of the leading arm than there is with the trailing arm.1 So you can again, decrease the impact on the painful shoulder1 by leading with the arm that's-- or that is painful.1 When you're using your momentum, it's important with transfers1 and then leaning your trunk forward1 as much as you're able to.1 So you guys can think of the number of transfers that you do1 in a day, multiply that by the year and then by the life span,1 transfers are a huge part1 of your ability to stay independent.1 If you're able to keep yourself to be able1 to transfer independently or safely or without pain,1 you really going to allow yourself to just sort of keep1 that quality of life, that independence1 that you want to be able to have.1 So the more that you can protect your shoulders while you're1 doing this, the more you preserve the ability to be able1 to continue your transfers, to continue to weight bear1 through those shoulders.1 1 So my final task performance, pressure relief,1 how many of you guys do pressure relief?1 Hopefully, everybody is raising their hand.1 Pressure relief, when I first started working1 in physical therapy without, this is what everybody1 that could to do the big press up, you know, full depression,1 lift all the way up, hold it for a minute, you know,1 really make sure that you're getting your body up1 and you get full clearance of your buttocks1 so you have no pressure on your buttocks.1 And it's still a great technique to be--1 relieve the pressure off your buttocks1 but it's really putting a lot of weight and a lot1 of strain on your shoulders.1 So if you're doing pressure relief every 15 to 20 minutes1 which is a recommended, and no, probably, not everybody is doing1 that all the time, you're really putting a lot of stress1 on your shoulders by just doing pressure relief.1 So maybe do a full release at one session1 and then the next 15 minutes,1 you're doing a lateral lean or a forward lean.1 You can see in the pictures here when you're leaning to the side,1 you're able to get one butt cheek completely off loaded1 from the pressure and then you would have to then go1 over to the other side.1 So you need to increase the amount of time1 that you're doing it rather than just sort of a straight lift1 because you can only get one side at a time1 but it's still effective.1 And in order to test it at home, you can just have somebody sort1 of reach their hand up and underneath.1 Can you feel any space between your buttocks1 and the seat cushion?1 Is that effective for pressure relief?1 1 Carrying objects, I know sometimes this is a hard thing1 to do to carry anything while you're pushing a wheelchair1 certainly, but having things closer to your body are--1 is easier than having things further away.1 So if you're holding something and holding it1 within outstretched arm, you put a lot of weigh1 through your shoulder, you put a lot of torque on your shoulder.1 If you bring the item closer to you, you're going1 to be a lot less painful, a lot less work1 to your shoulder joint.1 And then not reaching over head or pulling yourself1 onto like a trapeze or a bar that often that puts you1 into this internal rotation position,1 closes up the shoulder joint and makes it sort of hard1 to get yourself out of that painful position.1 1 So this is for-- for manual wheelchair mobility certainly,1 this is something that you can work on as well2 to decrease your shoulder pain as you're propelling2 or to preserve your shoulder function2 so you can continue to propel.2 Long smooth strokes, very important.2 And making sure that your contact point is at 11 o'clock,2 and releasing at 2 o'clock.2 So you don't want to start straight up at the top2 of the tire, you want to be a little bit behind and you want2 to be able to push smoothly and efficiently forward2 and then lightly release not quickly sort of pull back.2 So it's a nice gentle efficient stroke.2 So as your hand sort of releases the wheel, your thumb drops down2 and just sort of, you know, is light, it's not grabbing2 as they're coming back.2 You don't want to be pressing on the push rims really tightly.2 You don't want to get force this way.2 Again, as soon as I've got my shoulders this way I'm turning2 my shoulder in and I'm putting force, you know,2 through there that's--2 could potentially cause problems on the road.2 Another strategy is if you lose momentum and you're on a slope2 or an incline, instead of forcing your shoulders to do it2 as hard as you can, as fast as you can, take a break,2 turn your chair sideways,2 see if you can get a little bit of a rest.2 Ask for help getting up and down some of those inclines.2 And then the last thing I wanted to talk2 about was finding a rest position2 for your arms in the chair.2 I think this is important.2 I've had a couple of clients that have been really unsteady2 with their balance so they've needed to use their hands2 to support their trunk.2 So their hands always have to be in contact with something2 to be able to sit upright and that's really hard.2 As if you're sitting in your chair for 12 hours a day2 and your body is on, or your muscles are working2 for that 12 hours, they're going to be fatigued,2 they're going to wear out quicker.2 They're going to have a harder time sort2 of performing and doing other task.2 So if you're positioning as such that you're required2 to hold yourself up with your hands, then we really need2 to look at your positioning to see if we can get that better2 so you have your hands free to be able to move around2 and to be able to relax at the times2 when you don't need to use your hands.2 Having them on armrest, having them on your lap and again,2 if you, you know, if you're able to throughout the day,2 it's just sort of opening up your shoulders a little bit.2 And the same for power wheelchair users,2 keeping your arms away from your body, you know,2 trying to stretch them out a little bit2 when you're in a power tilt.2 Having them lean off to the side is helpful to sort of open2 up that shoulder joint to allow you to sort of keep, hopefully,2 prevent too much pain to that shoulder.2 So height of transfer for surface is another one.2 I think you guys probably have all experienced this with--2 you have a high transfer or getting down onto a floor,2 it puts a lot more strain on your shoulders2 and if you have either an even2 or what I consider a downhill surface.2 So if you're able to set up your environment2 that you're going downhill,2 more often than you're going steep uphill, again,2 you give yourself the advantage of decreasing them on a work2 that your shoulders have to do throughout the day,2 hopefully therefore, protecting2 and preserving your shoulder-- shoulder health.2 Of course you can't really do that with your bed.2 If you have your bed, that is not--2 if it's not a hospital bed, it's either going to be higher2 or lower getting in or getting out.2 So, you know, maybe making that an even transfer surface2 if you're able to-- if it is a hospital bed and you're able2 to get it low enough to get in and lift it up in high to get2 out that that would be ideal to be able to do.2 Keeping things accessible to you, keeping things2 that you use quite frequently in close proximity2 or in close reach, so you're not having to struggle2 to get any sort of accessible item, also,2 minimizing difficult terrain, so on a day,2 where your shoulder is painful2 or if you do have any shoulder pain going up and down the hills2 of Seattle, it's probably not a great idea or finding a way2 to get around, finding a way to sort of either avoid some2 of these really difficult terrain.2 And then the other-- the last thing about manual chairs is2 that your tire inflation is really, really important2 to the amount of effort that you use to push the chair.2 So if your tire inflation is poor, if it's really low,2 you're using more force to push your chair which translates2 to more strain on your shoulders which makes it more difficult2 to be able to get around.2 So maintaining your chair, making sure your chair's2 in good working order, I would usually recommend checking the2 tire inflation about once a week, you can also do2 that to sort of with filling to sort2 of seeing how it fills as you're going.2 The lower the tire pressure, the increasing--2 you increase the rolling resistance.2 So you increase the friction between your tire and the floor2 which makes it harder to push the chair around.2 2 Okay, any questions about sort of environment2 or changing task performance or positioning, before we dive2 into the strengthening stretching.2 Yeah. So the question is,2 if you have difficulty keeping yourself upright2 and you're always using your hands to support yourself,2 is it important to put armrest back on your wheelchair?2 And I don't think it-- it's an essential2 to put your armrest back on unless your arm rest prevent you2 from doing that or give you that position that you can rest in.2 If you feel like it's causing you pain throughout the day,2 because your hands are always touching something2 that aren't your armrest,2 then I think it would be a good trial, you know, to do.2 So the question is about for, you know,2 how to relieve back pain, and then how to sort of really,2 whether or not using your shoulders2 and for the supporting yourself is causing some of that pain,2 and it certainly could contribute to it.2 I would think that, you know, the first thing that you'd want2 to do is really look at your positioning in the chair.2 Is there anything that you can do2 to change your back rest position,2 to either to support you better, or to decrease some2 of the pain in your back?2 And then certainly talking a little bit about some2 of the movements, and maybe some of the stretching2 that we're going to go over here in just a little bit.2 It's a good question, okay.2 So, what I'm going to do next is these four articles here are2 sort of the four primary articles that are2 out in the research right now that talk about exercise,2 and spinal cord injury and related to pain.2 Most of these studies use what's called the wheelchair users,2 shoulder pain index which is a fancy, a research tool that sort2 of basically quantifies the amount of pain2 that people are having with daily activities.2 So some of the questions would be, are you having shoulder pain2 when you are transferring?2 You know, and then you give it a level, or an intensity level.2 So it gives you a score2 that shows you how much shoulder pain you have,2 you know, on the scale.2 So the studies are-- well, I'll go through each2 of them as we're going here.2 The first study is by Curtis [phonetic],2 and he showed 42 different wheelchair users,2 and divide them up in between two different groups.2 And the two different groups, one of them was a group2 that just received education.2 So somebody talk about the shoulders,2 or like we're doing tonight, and then they were given exercises2 that they were supposed to do.2 And then this other group was doing a little bit more2 of a controlled study.2 So they were actually being help through some of these exercises,2 and they got exercises for stretching,2 and for strengthening.2 And these exercises were for the pectoralis major,2 which is the muscle that's right here on your chest.2 This is the muscle that it's in the front.2 The pectoralis muscle does the most work2 when you're transferring.2 So it's very important muscle to one be able to use.2 So that muscle they wanted to be able to stretch,2 as well as your biceps.2 And your biceps also do a quite a bit2 of work throughout the day, and are often2 in a bent position instead of the stretched position2 which is straight out.2 The strengthening exercise2 that they choose was scapular retraction,2 and what that means is2 that you're bringing your shoulder blades,2 or your scapula closer together.2 Shoulder external rotation, or ER which is,2 you're rotating your shoulders out that's dealing2 with the rotator cuff.2 And then shoulder adduction, or meaning, this direction sort2 of towards your body, and this is the motion,2 or this is the action that the pectoralis major does.2 So this position is sort of strengthens that being.2 So they took there-- they chose muscles t