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Thread: Ask a PT

  1. #1

    Ask a PT

    It sounds like there are questions out there that I may be able to help answer. I am going to start with the question about exercising and shoulder pain.

    Obviously, shoulders were not made for the repetitive use and stress that they are put under when your arms are used for mobility. Shoulder pain is exacerbated by muscle imbalances - the primary motions/forces you are going through are pushing down. You push down to propel a wheelchair, you push down to transfer, you push down to do a pressure relief. All this use of the pecs cause them to get stronger and tighter. It brings your shoulder blades around the rib cage, giving a rounded shoulder look. This decreases the space on the front of the shoulder where all the rotator cuff tendons, peripheral nerves, and blood supply to the arms run. This can set up the rotator cuff tendons to rub on the acromion with overhead movement.

    What can help? First of all - stretch those pecs!! In a doorway is good (I'm hoping the picture I attach shows up) as long as you are getting your shoulder blade back and down. You could also lay on your back and open your arms up - increased the stretch with a towel roll down your spine. You also want to stretch your biceps because they too get tight when that shoulder blade is stuck in a forward position. For the doorway stretch, just straighten out your arm and turn more. You should feel the stretch down the biceps if you're doing it right.

    Stretch every day! Hold each for 20 seconds and do it 3 times.

    Exercising is great, but you don't want to work out those muscles that are already overused and tight. You want to work out those muscles that are supposed to hold your shoulder blade back. When those pecs are tight, and the shoulder blades are curved, the muscles in the back are lengthened, and therefore weaker. Exercise them to get them stronger while stretching to get those shoulder blades to stay back where they are supposed to be.
    A band is sufficient. Pullies are good too.

    1. Rows - holding arms straight out, pull the elbows back

    2. Shoulder external rotation - keep your elbow at your side, with a 90 degree angle, and pull the band/pulley away from your stomach

    3. Shoulder adduction - with you arm straight out to the side (don't go above the shoulder) pull the band straight down. Keep the elbow straight.

    4. This is a tricky one, if you hold your arms straight out in front of you, keeping the elbows straight, you want to push the arms forward so the shoulder blades come around the rib cage. Think of a boxer giving a hook and how the shoulder blade comes around to get a better reach.

    I would recommend a light weight that does NOT increase your pain, and doing 2 sets of 15, 3 times a week. If you have shoulder pain, ice your shoulders after the exercises. I know - ice sucks! No one likes it. But it helps! Keep it on for 20 minutes.

    Let me know if you have any questions. Hope that is a good start. Feel free to ask about anything you think a PT can help with.

    Kristin

  2. #2
    Senior Member
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    Wow, this is great. I am glad you are posting as many of us have questions that you will be invaluable answering. Thank you!

  3. #3
    This is really needed here. Thanks.
    You will find a guide to preserving shoulder function @
    http://www.rstce.pitt.edu/RSTCE_Reso...imb_Injury.pdf

    See my personal webpage @
    http://cccforum55.freehostia.com/

  4. #4
    Since I have not received any new questions, I will continue on the topic of exercising and shoulder pain. Do you exercise if it just add more wear and tear on your shoulder??

    This is a wonderful and complicated question... I am always a proponent of exercise! It is necessary to get the heart rate up to decrease the high risk that people with SCI are already at for heart disease and diabetes. But on the other hand, I would never recommend that someone exercise into unbearable pain. In PT school, they always stress "working in a pain-free range" - that's not always possible when your clients have constant shoulder pain.

    I would recommend, first trying the exercises and stretches above to see if the shoulder pain decreases. For cardio work, try workouts that emphasize those muscles in the back - whether it's aerobics, or riding a stationary arm crank backward, find something that does not increase your pain. Allow for at least one day of recovery, and again, I would recommend considering ice after the workout. If your pain increases, step it back. If it doesn't, stick with that workout for a week, then slowly start to increase it - by time OR by difficulty. Always listen to your body.

    For strengthening, I would recommend holding off on heavy weights until your decrease your shoulder pain. Again - do the exercises above, then as you progress, focus on increasing the strength of your back. Like rows for rhomboids, triceps, lats. Stay away from chest press and bicep curls because, again, these are the muscles that are strong and tight, and working them can increase your shoulder pain.

    Does that help? It's a fine line, with a lot of grey area. Let me know if you have questions.

    Let me know what other areas I can talk about.

  5. #5
    "We must overcome difficulties rather than being overcome by difficulties."

  6. #6
    Senior Member
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    Thanks for joining the forum and taking this on, and thanks for this particular post. Good advice with prehab to prevent shoulder injury, and rehab for dealing with it is sorely needed in the long term community.

    I am a T4 para, wife is post polio, both long time manual chair users, both have had experience with shoulder pain. I have long time multiple complete tears in both shoulders. An acquaintance told me that a Body Bar Flex had worked wonders for him. He said it was like magic, the pain was gone in a few days and he quickly regained function.

    The Body Bar Flex is a fiberglass rod inside a rubber casing that is about 4 feet long and about 1" in diameter. It weights about 1 pound. The idea is to bend, or flex, the bar. Flex is not lifting heavy weights. It was apparently developed by a composites engineer after a shoulder problem. The Flex 40 takes 40 pounds to squeeze the ends together and the Flex 20 takes 20 pounds.

    So we got a Flex 20. My wife described her problem as pain and felt like she was getting frozen shoulder. This developed over several years on and off, and this episode was several weeks duration. The usual PT exercises had not provided relief. Using the Flex 20 every other day was magic for her. The pain was gone within a week, and after a few weeks of use, she is transferring like I have not seen in years. Unassisted from her chair to a normal medical office exam table for example. My jaw is dropping.

    My experience was not so dramatic. The Flex 20 was too much for me, and Body Bar made me a special Flex 10 (which they are now marketing through their web site). My right shoulder has responded well. Not magic, but after months and months of pain, a few weeks work starting carefully with the Flex 20 and the moving to the Flex 10 when it arrived, my right shoulder is pain free and has regained a good deal of function. In particular I can turn the van's steering wheel without pain, and transfer (carefully) without right shoulder pain. Of course, I am still not pushing the 3 ~ 4 miles a day I used to, and in fact I am moving to a power chair. But my right shoulder is functional in the sense that I can drive, push short level distances, and transfer in my normal environment completely pain free.

    My left shoulder has not responded so well. It got better for awhile, but despite an abundance of caution, I have overstressed it and I am starting back from zero. Body Bar is making me a special Flex 5 to try.

    I should emphasize that the Body Bar is not repairing complete tears. It does seem almost magically effective in reducing pain in the 2 out of 3 people I know who have used it. It has also restored considerable function. In my case, the pain did go away but it took more time (this may be simply because I am 68 years old), and some function was restored. But I am still living with the fact that the tissue has complete tears.

    One other thing that has helped me is sleeping with pillows under my shoulders. I sleep on my stomach. This is a bad idea, but I just cannot stand it on my back, and don't dare sleep on either shoulder. I place a small pillow under each shoulder so my shoulders are pushed back. This made a big difference for me.

    I have a great deal of experience with the exercises in the original post, and endorse them. Also heartily endorse the pillow under the spine to flex the shoulders back. I use this as part of my morning exercise. YouTube has many rotator cuff exercise videos. Use common sense an do not overdo. The muscles involved are small, and big weights and heavy exercise is not the answer. If you remember nothing else, remember that "No Pain, No Gain" (which I adhered to for years) is absolute B** S*** Get as smart as you can and treat your rotators cuffs with gentle respect or they will introduce you to real misery.
    T4 complete, 150 ft fall, 1966. Completely fused hips, partially fused knees and spine, heterotopic ossification. Unsuccessful DREZ surgery about 1990. Successful bladder augmentation using small intestine about 1992. Normal SCI IC UTI problems culminating in a hospital stay in 2001. No antibiotics or doctor visits for UTI since 2001: d-mannose. Your mileage may vary.

  7. #7
    Are there any resources, videos etc. to show a person how to do ROM alone? I have full arm function...
    Emily, C-8 sensory incomplete mom to a 8 year old and a preschooler. TEN! years post.

  8. #8
    Emi2 - did you ever learn how to do range with a strap? We gave instruction and handouts to our patients in the hospital, but I will look for - or make a video for you.

  9. #9
    I thought about posting my own thread, but maybe you can give me some advice here, this is going to be a long one, so bear with me.

    First off I am a T7ish complete just under 30 years old, skinny and in reasonably good health from the ribcage up and I ride a TiLite ZRA. I just moved for school to a town that has "Hill" in the name, so I knew what I was in for. I am about 1.5 to 2 miles from the building where I will be taking classes and whatnot, and I was planning on just pushing my way to class every day, that way I could at least get my heart pumping a little bit every day. When I told my family members that, they told me that I'd probably ruin my shoulders before I finished school. How bad is it really to push yourself around in a chair?

    The first half to 3/4 of a mile is definitely uphill, I'd guess an average of 10% grade with some sections so steep that I've really got to lean down to keep my front wheels from coming up off the ground (my center of gravity is as far forward as my chair can go). Once I get here, the rest of the way is a little hilly, but nothing very extreme. When I get to the top of the hill (after the first 1/2 mile or so) I can definitely feel it in my triceps, they are worn out, but after waiting for the traffic lights at the top of the hill, where it is fairly flat, even my triceps feel fine by the time I get where I'm going.

    So how much of a risk would I be taking by pushing myself a hilly 2 miles to and from school every day?

  10. #10
    Funklab - Congrats on going to school! Good luck with your studies

    So the question is "will pushing uphill expedite shoulder pain?" Right? Surprisingly, the studies out there do not support that. It is correlated to the pattern used with propelling more than anything, and the younger a person is when they start using a chair, the more efficient they are and less shoulder pain.

    It does make some sense though. The positive thing about pushing uphill and leaning so far forward is that you are changing the forces on your shoulder - you can feel that when your triceps are worn out. The forces are always acting perpendicular to your push, so when your pushing on level ground, you're getting more force straight up into the shoulder, and when you're leaning forward, it is directed toward the back of your shoulder. This is the position wheelchair racers are placed in for that reason; bigger muscle groups are doing the work.

    Are you adding wear and tear to your shoulders by pushing 4 miles every day? Of course you are, but be sure to do your shoulder stretches and exercises that I wrote about in an earlier post, and hopefully you will keep your shoulders healthy.

    You can also look into Magic Wheels which double your work effort and do not let you roll backward when going uphill. They are pricy, but can be put on your Ti chair when you want to use them, and switched for your regular wheels when you don't.

    Hope that helps.

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