With a complete spinal cord injury, when legs cannot move, the independence of the person depends upon the upper limbs – Their arms. It is primordial to keep them in good shape, and far from the incapacitating pain. Yet still, shoulder, elbow and wrist pain are common. In spinal cord injuried population, 31-73% feel shoulder pain, 49-73% have a carpal tunnel syndrom (a painful wrist condition). Total, 59% of telegraphic people feel pain somewhat in their arms. For paraplegic people, it’s 41%.
Why?
Some causes has been found, mainly because of the posture, the way of propelling the wheelchair, and the transfers.
How to avoid pain
Studies about that subject are available. In 2005, a guideline has been published for healthcare professionals to prevent painful conditions of the arms. It is a long time ago. In 2015, a study has been published : Good new, the recommendations are still relevant and up-do-date, though clinical practices still need to be improved(2)
First Serial of recommendations – Wheelchair
Minimize cadence
Arm pain can be caused by repetitive movements. At what point a movement becomes repetitive ? More that one push per second. To avoid pain, you should rather do great and slow movements than small and fast ones.
Increase time contact with the pushrim
How to minimize cadence ? Do greater pushes. For that, you have to take the pushrim from the back, and bring it as far as possible frontwards. You should opt for the semi-circular technique rather than the arc one.
Why the semi-circular one ? I do fewer pushes!
Yes, and it was the goal : to lower the cadence. Also, it allows your hand to pass under the pushrim before doing another push : It allows an efficient rest for your arm.
I can’t do it : I cannot go that far back on the pushrim.
It may be because of your posture. We tend to facilitate an upper trunk posture as forward as possible (without interfering with balance). You should then try to avoid being axed backward. The chair can be adapted, if needed. The seat should be as high as possible regarding the wheel, to have an optimal position (100-120° elbow angle when the hand is on the top center of the pushrim).
Make sure to have a good flexibility
If you have important muscle retraction, refraining the wrist extension, it can interfere with the way you propel yourself with your chair. It can increase internal rotation of the shoulder, and create pain.
Weight
The force you need to propel your wheelchair should be as small as possible. What does it mean? A lighter chair is better, with good wheels, good rims, and correctly inflated tires. The less resistance you get, the more aerodynamic you’ll be! Moreover, it means you have to stay as light as possible yourself : Avoid gaining weight. It will get the propelling work easier, as well as the transferring tasks.
2nd serial of recommendations : Transfers
Avoid going to a higher surface
When possible, avoid complete extension of the wrist
Vary techniques
Try to transfer in both directions ; not always the same one. Go to the left – or the right- once in a while. If you already have pain to your shoulder, you could decrease it by leading with this arm (transfer to your left if your left shoulder is painful). Bending the trunk over the arm is efficient for a better force transmission.
Also, to release seat pressure, vary techniques. Bend forward, and on the sides. Don’t always use the same technique of lifting yourself with your arms.
Third serial of recommendations : Exercises
Every spinal cord injured person should have an exercise program to prevent upper limb pain, containing stretching and strengthening exercises. You don’t have any ? It would be a great idea to ask your fitness trainer of you physical therapist. Studies have established they are effective to prevent pain.
Stretching
Should be done 2-3X / week. You should keep every stretching position from 30 seconds to 2 minutes. It should focus on external rotation, scapula retraction (getting both scapulas closer from each other, in your back), to stretch pectoral muscles, and trapezius muscles.
Strengthening
Avoid internal rotation of the shoulder
You would like to learn more?
Bibliography
Healthcare professionals, go see the guideline to preserve upper limp function following spinal cord injury:
(1) Consortium for spinal cord medicine – Paralyzed Veterans of America (2005) Preservation of Upper Limb function following spinal cord injury : A clinical practice guideline for health-care professionals (disponible en ligne) <http://www.pva.org/CMSPages/GetFile.aspx?guid=046ed316-900d-4126-a2db-88bc510d9d94>
(2) Sawatzky, B., DiGiovine, C., Berner, T., Roesler, T., & Katte, L. (2015). The Need for Updated Clinical Practice Guidelines for Preservation of Upper Extremities in Manual Wheelchair Users. American Journal Of Physical Medicine & Rehabilitation, 94(4), 313-324. doi:10.1097/PHM.0000000000000203
(3) Boninger, M. L., Koontz, A. M., Sisto, S. A., Dyson-Hudson, T. A., Chang, M., Price, R., & Cooper, R. A. (2005). Pushrim biomechanics and injury prevention in spinal cord injury: Recommendations based on CULP-SCI investigations. Journal Of Rehabilitation Research & Development, 429-19. doi:10.1682/JRRD.2004.08.0103