A Patient’s guide to Looking After Your Shoulders following a Spinal Cord Injury (SCI)

Because increased weight and force is being put through your shoulders to allow you to transfer and move, your shoulders are more vulnerable to wear and tear if not looked after well. This can limit you later in life.

Shoulder pain is a common complication following spinal cord injury with reported prevalence ranging from 30-70%. Shoulder pain can impact on your sleep, functional ability and overall quality of life.

Research has found that shoulder strengthening and stretching exercises can reduce shoulder pain following a spinal cord injury. Improving your posture to aid shoulder alignment, considering the set up of your wheelchair (if appropriate) and reviewing your lifestyle can all help to reduce unnecessary strain to further protect your shoulders.

The purpose of this leaflet is to provide you with information to help you to look after your shoulders. Please ask for further information from your therapist if any of the following is unclear.

At the end of the booklet is an exercise programme, please follow these exercises in addition to any that have been prescribed by your Physiotherapist or Occupational Therapist.

The shoulder is one of the most mobile joints in the body allowing for movements in many different directions. With this wide range of movement comes reduced stability and vulnerability.

The shoulder joint is made up of the scapula (shoulder blade), clavicle (collar bone) and humerus (upper arm bone) which are connected by soft tissues. It is a shallow ball and socket joint and therefore heavily dependent on muscle activity for stability.

The shoulder joint and the shoulder blade together is called the shoulder girdle.

Movement takes place at the main shoulder joint glenohumeral joint (GHJ) as well as the shoulder blade (scapula).

The group of muscles called the rotator cuff (suprapinatus, infraspinatus, teres minor and subcapularis) plays an important role in allowing the shoulder joint to move efficiently, whilst at the same time providing stability to the joint to keep it aligned.

There are many possible causes of shoulder pain:

Posture

Poor posture can alter the biomechanics of the shoulder, for example, a slumped posture causes the shoulder blades to be pulled forwards and the shoulders to roll inwards. This leads to tightness of the muscles at the front of the shoulders and in the chest. As a result the muscles at the back of your shoulders can become lengthened and weaker. If your seating system has not been adjusted to provide you with stability, spinal alignment and side support you may well sit with excessive pressure going through your shoulders to try and compensate for the lack of stability.

Altered muscle length

Overly tight or overly loose muscles may change the position of your shoulder girdle when you are at rest and when you are moving.

Weakness

Shoulder weakness can cause an imbalance of muscles, which can, in turn, lead to shoulder joint instability, pressing on the soft tissue around your shoulder (impingement), muscle tears and subsequent wear and tear (degenerative joint disease).

Position when propelling wheelchair

Poor positioning in a wheelchair will cause poor push patterns which can put increased strain on your shoulders.

Ageing

As you age the additional wear and tear associated with being in a wheelchair and/or using a walking aid may lead to shoulder pain.

Repetitive use

Repeated use of your upper limbs for weight bearing and lifting items, such as lifting your wheelchair in and out of the car, increased requirement for lifting things from over head, places an increased amount of stress on your shoulder joints and soft tissues.

Impingement

Soft tissue around your shoulder can get pressed against the bones in the joint as you move your arm, especially if seated poorly.

Pre-existing joint instability

Pre-existing soft tissue issues could result in the shoulder joint being less stable. This could make upper limb activities harder with increased force through weaker shoulders which in turn leads to additional wear and tear. Trauma Direct trauma at the time of your injury or any other time can result in damage which may cause altered function in your shoulders and give you more pain.

Postural alignment

Check your posture for any asymmetries, e.g. one shoulder higher than the other, or one knee further forward than the other. Also consider if you are sitting with a neutral pelvis (picture 1) or if your pelvis tilts forwards or backwards (picture 2).

If you think there is a problem with your posture when sitting in your wheelchair speak to your Occupational Therapist for further advice.

Propelling your manual wheelchair

Your wheelchair should be set up to optimise your access to the wheels for efficient pushing. Recommended positioning in your wheelchair when seated with postural support would allow your middle finger tip to touch the axle at the center of the wheel; this allows optimal pushing technique with ease of access to the wheel rims.

A recommended pushing technique is using a circular motion, allowing the hands to drop free at the end of the push and return to the rear of the wheel which allows a short rest for your shoulders (see picture 3).

• Complete pressure relief using a forward lean technique (rather than lifting) for the recommended consecutive two minutes every hour.
• Try to minimise the number of transfers you do in a day and aim to make your most frequent transfer surfaces at home the same height for these transfers.
• Limit the number of domestic activities you do in one go e.g. clean the kitchen one day, clean the bathroom the next day.
• Avoid twisting to access work surfaces and re-arrange cupboards to avoid over reaching either up or down.
• Try to avoid weight gain and reduce your weight if heavier than your optimal Body Mass Index (BMI) as this will place more load on your joints. Contact your GP or LSCIC Consultant for a referral to a dietician if required.
• If you are having pain or difficulty moving around in bed, it may be useful to consider an electrical profiling bed and the use of sliding sheets to help you move in bed either with or without the assistance of a carer.
• Consider use of power assist wheels or a power wheelchair to reduce the effort required to push your wheelchair over longer distances.
• Consider alternatives to lifting a wheelchair in/out of a car e.g. wheelchair accessible vehicle or roof-top box.
• Ask your Occupational Therapist for a review of your posture in your wheelchair.

Please complete the following exercises if the circle has been ticked by your therapist.

Strengthening of muscles around the shoulder girdle can improve the efficiency of movements. The following exercises target the rotator cuff muscles.

Place your elbow and forearm on a table in front of you with your elbow bent at a right angle. Rotate your arm out to the side and back in to your body. Try to keep the movement as smooth as possible.

Repeat 10 times on each arm.

Lying on your back. Place your arm out to the side with your elbow bent at a right angle so the palm of your hand faces the ceiling.

Rotate your arm down so your forearm rests with the palm of your hand facing downwards to the bed.

Repeat 10 times on each arm.

Resistance band exercises

Sit with your elbow bent at a right angle. Keep the elbow tucked in against your body and your hand placed on the tummy. Pull your hand and the theraband out towards the side as far as possible. Keep your elbow tucked in and your wrist straight during the movement. Slowly return to starting position. Repeat 10 times on each arm.

Sit with your elbow bent at a right angle. Keep the elbow against your body and place your hand out towards the side.

Pull your hand and the theraband towards your tummy. Keep your wrist straight during the movement. Slowly return to starting position. Repeat 10 times on each arm.

Sit with your elbows slightly bent in front of you. Pulling the resistance band towards you in a rowing like motion backwards while bringing the shoulder blades together. Repeat 10 times.

The muscles at the front of your shoulders can become short and tight when propelling your wheelchair or using a walking aid. The following stretches will help to avoid this.

Lying flat on your back, take your arms out to the side and place your hands behind your head, resting your elbows on the pillow. Hold your arms here for 30 seconds. You can do this exercise one arm at a time if you want to. Repeat 3 times.

Stand or position your wheelchair in a door frame. Place your hand and forearm against the door frame and then turn your upper body away from the door frame so you stretch the muscles across the front of your chest. Hold this position for 30 seconds then do your other side.