Shoulder Pain Prevention Program for Manual Wheelchair Users With Paraplegia: A Randomized Clinical Trial.

Objectives: To compare prevalence of shoulder pain (SP) onset over 3 years for individuals with paraplegia from spinal cord injury who participate in one of two shoulder pain prevention program (SPPP) formats with that of a similar population without intervention, and to compare exercise adherence between two SPPP formats. Methods: The randomized clinical trial (compared to historical controls) included a volunteer sample of 100 individuals without SP at study entry. Eighty-seven participants returned for assessments at 18 and 36 months after study entry. Control group included 220 volunteers from a 3-year observational study with identical inclusion criteria. SPPPs included shoulder home exercises and recommendations to improve mobility techniques that are effective in reducing existing SP in this population. Participants were randomly assigned to receive either one instruction session and a refresher session 4 weeks later with a physical therapist or a 4-week series of 2-hour group classes taught by a physical therapist and peer mentor. Prevalence of SP onset at 18 and 36 months and self-reported average weekly exercise frequency were the main outcome measures. Results: SP onset was identical in the two SPPPs but was significantly lower at 18 and 36 months in both groups (11% and 24%) compared to controls (27% and 40%, p < .05). Self-reported average weekly exercise frequency was similar between intervention groups but was significantly lower during the first 4 months in participants who developed SP compared to those without pain (2.12 ± 1.0 vs. 3.01 ± 1.13, p < .05). Conclusion: SPPPs reduced SP onset prevalence regardless of instruction format. Exercise adherence was important to the outcome of shoulder pain.

Effect of reverse manual wheelchair propulsion on shoulder kinematics, kinetics and muscular activity in persons with paraplegia.

Objective: Shoulder pain after spinal cord injury (SCI) is attributed to increased mobility demands on the arms and negatively impacts independence and quality of life. Repetitive superior and posterior shoulder joint forces produced during traditional wheelchair (WC) locomotion can result in subacromial impingement if unopposed, as with muscular fatigue or weakness. ROWHEELS® (RW), geared rear wheels that produce forward WC movement with backward rim pulling, could alter these forces. Design: Cross sectional. Setting: Research laboratory at a rehabilitation hospital. Participants: Ten manual WC users with paraplegia. Outcome measures: Propulsion characteristics and right upper extremity/trunk kinematics and shoulder muscle activity were collected during ergometer propulsion: (1) self-selected free speed reverse propulsion with RW, (2) matched-speed reverse (rSW), and (3) forward propulsion (fSW) with instrumented Smartwheels (SW). Inverse dynamics using right-side SW rim kinetics and kinematics compared shoulder kinetics during rSW and fSW. Results: Free propulsion velocity, cycle distance and cadence were similar during RW, rSW and fSW. Overall shoulder motion was similar except that peak shoulder extension was significantly reduced in both RW and rSW versus fSW. Anteriorly and inferiorly directed SW rim forces were decreased during rSW versus fSW propulsion, but posteriorly and superiorly directed rim forces were significantly greater. Superior and posterior shoulder joint forces and flexor, adductor, and external rotation moments were significantly less during rSW, without a significant difference in net shoulder forces and moments. Traditional propulsive-phase muscle activity was significantly reduced and recovery-phase muscle activity was increased during reverse propulsion. Conclusion: These results suggest that reverse propulsion may redirect shoulder demands and prevent subacromial impingement, thereby preventing injury and preserving independent mobility for individuals with paraplegia.

Use of Game Theory to model patient engagement after surgery: a qualitative analysis.

BACKGROUND: Patient engagement is challenging to define and operationalize. Qualitative analysis allows us to explore patient perspectives on this topic and establish themes. A game theoretic signaling model also provides a framework through which to further explore engagement. METHODS: Over a 6-mo period, thirty-eight interviews were conducted within 6 wk of discharge in patients undergoing thyroid, parathyroid, or colorectal surgery. Interviews were transcribed, anonymized, and analyzed using the NVivo 11 platform. A signaling model was then developed depicting the doctor-patient interaction surrounding the patient's choice to reach out to their physician with postoperative concerns based upon the patient's perspective of the doctor's availability. This was defined as "engagement". We applied the model to the qualitative data to determine possible causations for a patient's engagement or lack thereof. A private hospital's and a safety net hospital's populations were contrasted. RESULTS: The private patient population was more likely to engage than their safety-net counterparts. Using our model in conjunction with patient data, we determined possible etiologies for this engagement to be due to the private patient's perceived probability of dealing with an available doctor and apparent signals from the doctor indicating so. For the safety-net population, decreased access to care caused them to be less willing to engage with a doctor perceived as possibly unavailable. CONCLUSIONS: A physician who understands these Game Theory concepts may be able to alter their interactions with their patients, tailoring responses and demeanor to fit the patient's circumstances and possible barriers to engagement.

Objective and Self-Reported Physical Activity Measures and Their Association With Depression and Satisfaction With Life in Persons With Spinal Cord Injury.

OBJECTIVE: To identify associations between objective and self-reported measures of physical activity (PA) and relationships with depression and satisfaction with life (SWL) in persons with spinal cord injury (SCI). DESIGN: Retrospective, cross-sectional study of objectively measured wheelchair propulsion (WCP) from 2 studies in which an odometer was attached to participants' wheelchairs to record daily speed and distance. Self-reported data were collected in a separate study examining dyspnea, PA, mood, and SWL. SETTING: Outpatient clinic in a rehabilitation center. PARTICIPANTS: Individuals (N=86) with traumatic SCI who use a manual wheelchair. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Objective measures of PA included average daily distance and speed of WCP measured by an odometer. Self-report questionnaires included demographics, the 24-hour recall of transfers, Physical Activity Recall Assessment for People with SCI, the Patient Health Questionnaire-2 (PHQ-2) to document depressive symptoms, and the Satisfaction With Life Scale (SWLS). RESULTS: Both objective measures of WCP, average daily distance and speed, were predicted by the combination of self-reported daily time away from home/yard and lower frequency of car transfers ([r=.367, P=.002] and [r=.434, P<.001], respectively). Daily distance of WCP was negatively correlated with depression (PHQ-2) (r=-.309, P=.004). Time in leisure PA was the only significant predictor of SWLS scores (r=.321, P=.003). CONCLUSIONS: Short-term recall of hours away from home/yard not spent driving or riding in a vehicle is suggested as a self-report measure that is moderately related to overall WCP PA in this population. Results of this study suggest that depression is related to decreased PA and WCP activity, while SWL is related to leisure PA.

Body mass index changes over 3 years and effect of obesity on community mobility for persons with chronic spinal cord injury.

OBJECTIVE: To identify the prevalence of obesity in persons with chronic spinal cord injury (SCI), determine change in body mass index (BMI) over time, and identify impact of obesity on community mobility. DESIGN: Prospective three year longitudinal study. SETTING: Outpatient clinic of rehabilitation center. PARTICIPANTS: Convenience sample of 222 persons with paraplegia between 2-20 years post SCI. OUTCOME MEASURES: BMI at baseline and three years; community mobility (daily wheelchair propulsion distance and velocity, average number of daily transfers and depression raises). RESULTS: Participants were 34.1 (27.3, 40.3) years of age and median duration of SCI was 8.7 (3.2, 15.1) years. The SCI adjusted BMI classification identified 44% of participants as obese. BMI increased over time with 13% moving into a higher weight category. Median change in BMI was 0.46 (-0.92, 1.50) kg/m (2) (z = -2.684, P = 0.007), and increased at a rate of 0.15 kg/m(2)/yr. Average BMI was negatively correlated with daily wheelchair propulsion distance (r = -0.179, P = 0.009), however there was no significant relationship with velocity, number of daily transfers or depression raises. CONCLUSION: The majority of participants with chronic SCI were overweight (23%) or obese (44%) and BMI increased by 0.46 kg/m(2) over three years. Those with higher BMIs pushed their wheelchairs shorter distances, but other mobility measures were not impacted by body weight. Continued mobility activities with increasing body weight can increase risk for shoulder injury. Identifying persons who are obese allows for directed and timely health and mobility intervention.

Relationship Between Hand Contact Angle and Shoulder Loading During Manual Wheelchair Propulsion by Individuals with Paraplegia.

BACKGROUND: Shoulder loading during manual wheelchair propulsion (WCP) contributes to the development of shoulder pain in individuals with spinal cord injury (SCI). OBJECTIVE: To use regression analysis to investigate the relationships between the hand contact angle (location of the hand on the pushrim at initial contact and release during the push phase of the WCP cycle) with propulsion characteristics, pushrim forces, and shoulder kinetics during WCP in individuals with paraplegia. METHODS: Biomechanical data were collected from 222 individuals (198 men and 24 women) with paraplegia from SCI during WCP on a stationary ergometer at a self-selected speed. The average age of participants was 34.7 years (±9.3), mean time since SCI was 9.3 years (±6.1), and average body weight was 74.4 kg (±15.9). The majority (n = 127; 56%) of participants had lower level paraplegia (T8 to L5) and 95 (42%) had high paraplegia (T2 to T7). RESULTS: Increased push arc (mean = 75.3°) was associated with greater velocity (R = 0.384, P < .001) and cycle distance (R = 0.658, P < .001) and reduced cadence (R = -0.419, P <.001). Initial contact angle and hand release angles were equally associated with cycle distance and cadence, whereas a more anterior release angle was associated with greater velocity (R = 0.372, P < .001). When controlling for body weight, a more posterior initial contact angle was associated with greater posterior shoulder net joint force (R = 0.229, P = .001) and greater flexor net joint moment (R = 0.204, P = .002), whereas a more anterior hand release angle was significantly associated with increased vertical (R = 0.270, P < .001) and greater lateral (R = .293, P < .001) pushrim forces; greater shoulder net joint forces in all 3 planes - posterior (R = 0.164, P = .015), superior (R = 0.176, P = .009), and medial (R = 0.284, P < .001); and greater external rotator (R = 0.176, P = .009) and adductor (R = 0.259, P = .001) net joint moments. CONCLUSIONS: Current clinical practice guidelines recommend using long, smooth strokes during manual WCP to reduce peak shoulder forces and to prevent shoulder pain development. The position of the hand at both initial contact and hand release must be considered in WCP training. It is recommended that participants should reach back to initiate contact with the pushrim to maximize push arc but avoid a more anterior hand position at release, because this could increase shoulder load during the push phase of WCP.

Car Transfer and Wheelchair Loading Techniques in Independent Drivers with Paraplegia.

Car transfers and wheelchair (WC) loading are crucial for independent community participation in persons with complete paraplegia from spinal cord injury, but are complex, physically demanding, and known to provoke shoulder pain. This study aimed to describe techniques and factors influencing car transfer and WC loading for individuals with paraplegia driving their own vehicles and using their personal WCs. Sedans were the most common vehicle driven (59%). Just over half (52%) of drivers place their right leg only into the vehicle prior to transfer. Overall, the leading hand was most frequently placed on the driver's seat (66%) prior to transfer and the trailing hand was most often place on the WC seat (48%). Vehicle height influenced leading hand placement but not leg placement such that drivers of higher profile vehicles were more likely to place their hand on the driver's seat than those who drove sedans. Body lift time was negatively correlated with level of injury and age and positively correlated with vehicle height and shoulder abduction strength. Drivers who transferred with their leading hand on the steering wheel had significantly higher levels of shoulder pain than those who placed their hand on the driver's seat or overhead. The majority of participants used both hands (62%) to load their WC frame, and overall, most loaded their frame into the back (62%) vs. the front seat. Sedan drivers were more likely to load their frame into the front seat than drivers of higher profile vehicles (53 vs. 17%). Average time to load the WC frame (10.7 s) was 20% of the total WC loading time and was not related to shoulder strength, frame weight, or demographic characteristics. Those who loaded their WC frame into the back seat had significantly weaker right shoulder internal rotators. Understanding car transfers and WC loading in independent drivers is crucial to prevent shoulder pain and injury and preserve community participation.

Shoulder Strength and Physical Activity Predictors of Shoulder Pain in People With Paraplegia From Spinal Injury: Prospective Cohort Study.

BACKGROUND: Shoulder joint pain is a frequent secondary complaint for people following spinal cord injury (SCI). OBJECTIVE: The purpose of this study was to determine predictors of shoulder joint pain in people with paraplegia. METHODS/DESIGN: A 3-year longitudinal study was conducted. Participants were people with paraplegia who used a manual wheelchair for at least 50% of their mobility and were asymptomatic for shoulder pain at study entry. Participants were classified as having developed shoulder pain if they experienced an increase of ≥10 points on the Wheelchair User's Shoulder Pain Index in the 3-year follow-up period. Measurements of maximal isometric shoulder torques were collected at study entry (baseline), 18 months, and 3 years. Daily activity was measured using a wheelchair odometer, and self-reported daily transfer and raise frequency data were collected by telephone every 6 weeks. RESULTS: Two hundred twenty-three participants were enrolled in the study; 39.8% developed shoulder pain over the 3-year follow-up period. Demographic variables and higher activity levels were not associated with shoulder pain onset. Baseline maximal isometric torque (normalized by body weight) in all shoulder muscle groups was 10% to 15% lower in participants who developed shoulder pain compared with those who remained pain-free. Lower shoulder adduction torque was a significant predictor of shoulder pain development (log-likelihood test=11.38), but the model explained only 7.5% of shoulder pain onset and consequently is of limited clinical utility. LIMITATIONS: Time since SCI varied widely among participants, and transfer and raise activity was measured by participant recall. CONCLUSIONS: Participants who developed shoulder pain had decreased muscle strength, particularly in the shoulder adductors, and lower levels of physical activity prior to the onset of shoulder pain. Neither factor was a strong predictor of shoulder pain onset.

Surgeons as medical school educators: an untapped resource.

Despite extensive experience teaching residents, surgeons are an untapped resource for educating medical students. We hypothesized that by involving surgeons as teachers earlier in the medical school curriculum, medical students' interest in surgery will increase and their opinions of surgeons will improve. Five programs designed to involve surgeons as educators in the medical school curriculum were implemented. The first program, started in 2008, introduced surgical faculty into the first-year medical student anatomy dissection laboratories. Other programs initiated in 2008 included: Surgical Clinical Correlates in Anatomy, which involved faculty teaching through cadaver surgery; Clinical Pathologic Conferences in Anatomy, a surgeon-led conference based on clinical cases; and a women's faculty-student mentorship program. Table Rounds, a surgeon-led anatomy review that used clinical scenarios to quiz students was begun in 2009. All five programs were successfully integrated into the medical school curriculum. While student opinion of surgeons as educators improved, there were no significant changes in student interest in surgery as a career nor change in performance on written examinations over the Anatomy content covered by the surgeons. Surgical faculty and trainees can be integrated into the medical school curriculum. Involving surgeons as educators earlier in the medical school curriculum may have longer term effects than could be observed in this study. At a minimum, the experience improved student opinion of surgeons as educators.

Strengthening and optimal movements for painful shoulders (STOMPS) in chronic spinal cord injury: a randomized controlled trial.

BACKGROUND: Shoulder pain is a common problem after spinal cord injury (SCI), with negative effects on daily activities and quality of life (QOL). OBJECTIVE: The purpose of this study was to determine the effect of an exercise program and instruction to optimize performance of upper-extremity tasks on shoulder pain in people with paraplegia from SCI. METHODS: Design Eighty individuals with paraplegia from SCI and shoulder pain were randomly assigned to receive either an exercise/movement optimization intervention or an attention control intervention. The exercise/movement optimization intervention consisted of a 12-week home-based program of shoulder strengthening and stretching exercises, along with recommendations on how to optimize the movement technique of transfers, raises, and wheelchair propulsion. The attention control group viewed a 1-hour educational video. Outcome measures of shoulder pain, muscle strength (force-generating capacity), activity, and QOL were assessed at baseline, immediately after intervention, and 4 weeks later. RESULTS: Shoulder pain, as measured with the Wheelchair User's Shoulder Pain Index, decreased to one third of baseline levels after the intervention in the exercise/movement optimization group, but remained unchanged in the attention control group. Shoulder torques, most 36-Item Short-Form Health Survey questionnaire (SF-36) subscale scores, and QOL scores also were improved in the exercise/movement optimization group, but not in the attention control group. Improvements were maintained at the 4-week follow-up assessment. Limitations Many of the outcome measures were self-reported, and the participant dropout rate was high in both groups. Additional studies are needed to determine whether the results of this study can be generalized to individuals with tetraplegia. CONCLUSIONS: This home-based intervention was effective in reducing long-standing shoulder pain in people with SCI. The reduction in pain was associated with improvements in muscle strength and health-related and overall QOL.

Comparison of shoulder muscle electromyographic activity during standard manual wheelchair and push-rim activated power assisted wheelchair propulsion in persons with complete tetraplegia.

OBJECTIVES: To compare spatio-temporal propulsion characteristics and shoulder muscle electromyographic activity in persons with cervical spinal cord injury propelling a standard pushrim wheelchair (WC) and a commercially available pushrim-activated power assisted wheelchair (PAPAW) design on a stationary ergometer. DESIGN: Repeated measures. SETTING: Motion analysis laboratory within a rehabilitation hospital. PARTICIPANTS: Men (N=14) with complete (American Spinal Injury Association grade A or B) tetraplegia (C6=5; C7=9). INTERVENTION: Participants propelled a standard pushrim WC and PAPAW during 3 propulsion conditions: self-selected free and fast and simulated 4% or 8% graded resistance propulsion. MAIN OUTCOME MEASURES: Median speed, cycle length, cadence, median and peak electromyographic activity intensity, and duration of electromyographic activity in pectoralis major, anterior deltoid, supraspinatus, and infraspinatus muscles were compared between standard pushrim WC and PAPAW propulsion. RESULTS: A significant (P<.05) decrease in electromyographic activity intensity and duration of pectoralis major, anterior deltoid, and infraspinatus muscles and significantly reduced intensity and push phase duration of supraspinatus electromyographic activity at faster speeds and with increased resistance were seen during PAPAW propulsion. CONCLUSIONS: For participants with complete tetraplegia, push phase shoulder muscle activity was decreased in the PAPAW compared with standard pushrim WC, indicating a reduction in demands when propelling a PAPAW.

Surgical clinical correlates in anatomy: design and implementation of a first-year medical school program.

Medical students state the need for a clinically oriented anatomy class so to maximize their learning experience. We hypothesize that the first-year medical students, who take the Surgical Clinical Correlates in Anatomy program, will perform better than their peers in their anatomy course, their surgical clerkships and ultimately choose surgical residencies. We designed and recently implemented this program for first-year medical students. It consisted of General Surgical Knowledge, Orthopedic Surgery, Plastic Surgery, Urology, Cardiothoracic Surgery, General Surgery, Vascular Surgery, and Ear, Nose, and Throat (ENT) sessions. Each session had defined learning objectives and interactive cadaveric operations performed by faculty members and students. The program was elective and had 25 participants randomly chosen. An evaluative questionnaire was completed before and after the program. Comparative analysis of the questionnaires, first-year anatomy examination results, clinical surgical rotation scores, and residency match results will be completed. The positive opinions of surgeons increased for all medical students from the pre-evaluation to the post-evaluation, and there was a greater increase in positive opinions for our participants. Our participants also had the highest average overall for all combined anatomy examinations. A need exists among medical students to develop a clinically correlated anatomy program that will maximize their learning experience, improve their performance and allow them to make moreinformed career choices. The recent implementation of this Surgical Clinical Correlates in Anatomy program fulfills this need.

Impact of Gender on Shoulder Torque and Manual Wheelchair Usage for Individuals with Paraplegia: A Preliminary Report.

BACKGROUND: The prevalence of women with spinal cord injury is increasing, and their unique attributes merit attention, specifically, shoulder strength and community wheelchair propulsion. RESULTS: Shoulder torques were 62%-96% greater in men than women, average daily distance traveled was greater for men, and average speeds were similar. CONCLUSIONS: Community wheelchair propulsion speed was similar between men and women but men were significantly stronger, therefore daily mobility requires a higher relative effort for women's shoulder muscles. This demand may increase susceptibility to fatigue and development of shoulder pain.

Shoulder muscular demand during lever-activated vs pushrim wheelchair propulsion in persons with spinal cord injury.

BACKGROUND/OBJECTIVE: The high demand on the upper limbs during manual wheelchair (WC) use contributes to a high prevalence of shoulder pathology in people with spinal cord injury (SCI). Lever-activated (LEVER) WCs have been presented as a less demanding alternative mode of manual WC propulsion. The objective of this study was to evaluate the shoulder muscle electromyographic activity and propulsion characteristics in manual WC users with SCI propelling a standard pushrim (ST) and LEVER WC design. METHODS: Twenty men with complete injuries (ASIA A or B) and tetraplegia (C6, n = 5; C7, n = 7) or paraplegia (n = 8) secondary to SCI propelled ST and LEVER WCs at 3 propulsion conditions on a stationary ergometer: self-selected free, self-selected fast, and simulated graded resistance. Average velocity, cycle distance, and cadence; median and peak electromyographic intensity; and duration of electromyography of anterior deltoid, pectoralis major, supraspinatus, and infraspinatus muscles were compared between LEVER and ST WC propulsion. RESULTS: Significant decreases in pectoralis major and supraspinatus activity were recorded during LEVER compared with ST WC propulsion. However, anterior deltoid and infraspinatus intensities tended to increase during LEVER WC propulsion. Participants with tetraplegia had similar or greater anterior deltoid, pectoralis major, and infraspinatus activity for both ST and LEVER WC propulsion compared with the men with paraplegia. CONCLUSIONS: Use of the LEVER WC reduced and shifted the shoulder muscular demands in individuals with paraplegia and tetraplegia. Further studies are needed to determine the impact of LEVER WC propulsion on long-term shoulder function.

A comparison of shoulder joint forces during ambulation with crutches versus a walker in persons with incomplete spinal cord injury.

OBJECTIVE: To compare 3-dimensional (3D) shoulder joint reaction forces and stride characteristics during bilateral forearm crutches and front-wheeled walker ambulation in persons with incomplete spinal cord injury (SCI). DESIGN: Cross-sectional cohort study. SETTING: Biomechanics laboratory. PARTICIPANTS: Fourteen adult volunteers with incomplete SCI recruited from outpatient rehabilitation hospital services. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Peak force, rate of loading, and force-time integral were compared for each component of the net 3D shoulder joint reaction force during ambulation with crutches and a walker. Stride characteristics were also compared between assistive device conditions. RESULTS: The largest weight-bearing force was superiorly directed, followed by the posterior force. The superior joint force demonstrated a significantly higher peak and rate of loading during crutch walking (48.9N and 311.6N/s, respectively, vs 45.3N and 199.8N/s, respectively). The largest non-weight-bearing force was inferiorly directed with a significantly greater peak occurring during crutch ambulation (43.2N vs 23.6N during walker gait). Walking velocity and cadence were similar; however, stride length was significantly greater during crutch walking (62% vs 58% of normal). CONCLUSIONS: Shoulder joint forces during assisted ambulation were large. Crutch use increased the superior force but did not increase walking velocity.